THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 

PUBUC 
HEALTH 
UBRABY 


Digitized  by  tine  Internet  Arciiive 

in  2008  with  funding  from 

IVIicrosoft  Corporation 


littp://www.arcliive.org/details/compendioussysteOOdewericli 


COMPENDIOUS    SYSTEM 

OP 

MIDWIFERY, 

CHIEFLY    DESIGNED    TO    FACILITATE   THE 

INQUIRIES 

OF  THOSE  WHO  MAY  BE  PURSUING  THIS  BRANCH  OF  STUDY. 

UXUSTRATED  BY  OCCASIOKAIi  CASKS. 

WITH  MANY  ENGRAVINGS. 


SIXTH  EDITION,   WITH  ADDITIONS  AND  IMPROVEMENTS, 


BY  WILLIAM  P.  DEWEES,  M.  D. 

ADJUNCT  PROFESSOR  OF  MIDWIFERY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA  ;  MEMBER  OF 

THE  AMERICAN  PHILOSOPHICAL  SOCIETY  ;  MEMBER  OF  THE  PHILADELPHIA 

MEDICAL  SOCIETY  ;   OF   THE    ROYAL    MEDICAL    SOCIETY   OF 

DENMARK,   &-C.    &-C. 


PHILADELPHIA  : 
CAREY,  LEA  &  BLANCHARD,  CHESTNUT  STREET 

1833. 


EASTERN  DISTRICT  OF  PENNSYLVANIA,  to  wit  : 

BE  IT  REMEMBERED,  That  on  the  thirteenth  day  of 

(L.  S.)     January,  in  the  fiftieth  year  of  the  indepenence  of  the  United 
States  of  America.  A.  D.'  1826,  Wilham  P.  Dewees,  M.  D.  of  the 
said  District,  hath  deposited  in  this  Office  the  Title  of  a  Book  the  right  where- 
of he  claims  as  author  in  the  words  following  to  wit: 

"A  Compendious  System  of  Midwifery,  chiefly  designed  to  facilitate  the  In- 
"  quiries  of  those  who  may  be  pursuing  tliis  branch  of  study.  Illustrated  by 
"  occasional  Cases.  With  tliirteen  engi-avings.  Second  Edition,  with  Additions, 
"  &c.  By  Wm.  P,  Dewees,  M.  D.  Adjunct  Professor  of  Midwifery  in  the  Um- 
«' varsity  of  Pennsylvania,  Member  of  the  American  Philosophical  Society, 
"Sic.  &c." 

In  conformity  to  the  act  of  Congress  of  the  United  States,  entitled  '« An  act 
for  the  encouragement  of  learning,  by  securing  the  copies  of  maps,  charts, 
and  books,  to  tlie  authors  and  proprietors  of  such  copies,  during  the  times 
therein  mentioned," — And  also  to  the  act,  entitled,  "  An  act  supplementary  to 
an  act,  entitled,  'An  act  for  the  encovu-agement  of  learning,  by  securing  the 
copies  of  maps,  charts,  and  books,  to  the  authors  and  proprietors  of  such  co- 
pies during  the  times  therein  mentioned,'  and  extending  the  benefits  thereof  to 
the  Arts  of  designing,  engraving,  and  etching,  historical  and  other  prints." 

D.  CALDWELL, 
Clerk  of  the  Eastern  District  of  Pennsylvatiia. 


PUBUC 
HEALTH 


TO  G^eS® 

PHILIP  S.  PHYSICK,  M.  D. 

pnoFESson  of  anatomy  in  thf.  university  of  Pennsylvania,  f.tc. 

MY  EARLY  AND  FAITHFUL  FRIEND, 

THE  SPLENDOUR  OF  WHOSE  PROFESSIONAL  REPUTATION 

IS  ONLY  EXCEEDED  BY 

THE  PURITY  OF  HIS  PRIVATE  CHARACTER, 
THIS  VrORK, 

THE  ItESULT  OF  MY  INaUIRIES,   OBSEUVATIONS,  AND   REFLECTIONS, 
ON  AN   IMPORTANT  SUBJECT, 

IS  AFFECTIONATFLY  INSCRIBED,  BY 

WM.  P.  DEWEES 


iviS752S4 


CONTENTS, 


PAGE 

Introduction     .  .  .  •  .  .  .  11 

CHAPTER  I. 

Sect.  I.  Of  the  Pelvis       .......        17 

II.  Of  the  Sacrum  ......  18 

III.  Of  the  Coccyx     .......        19 

IV.  Of  the  Ossalnnominata         .....  20 
*      V.  Of  the  Separation  of  the  Bones  of  the  Pelvis     .             .             .21 

VI.  Of  the  Deformity  of  the  Pelvis         ....  28 

VII.  Examination  of  the  Pelvis  .  .  .  .  .37 

CHAPTER  n. 

Ofthe  Child's  Head    .......  40 

CHAPTER  HI. 

Of  the  Genital  Organs       .  .  •  .  •  .  .44 

Sect.  I.  Of  the  Internal  Org-ans  .  ...  .  .  48 

II.  Of  the  Uterus  and  its  Dependencies         .  .  .  .49 

CHAPTER  IV. 

Of  the  Efficient  and  Final  Cause  of  the  Menses  ...  58 

Sect.  I.  Of  Lvmar  Influence  ......  62 

II.  The  General  Plethora  Doctrine         ....  63 

III.  TojMcal  Congestion  ......  65 

IV.  Final  Cause  "......  68 

CHAPTER  V. 

Of  Conception       ........        70 

Sect.  I.  Graviditas  in  Uteri  Substantia,  or  Graviditas  Interstitialis     .  72 

CHAPTER  VI. 

Of  the  Changes  produced  by  Conception  .  •  .  .73 

Sect.  I.  Tlie  Membranes         ......  78 

II.  The  Placenta  .  •  •  -  .81 

ni.  Foetal  Circulation       ......  83 

IV.  Of  the  Changes  wliich  take  place  in  the  Uterus  from  Impregna- 
tion     .  .  .  •  •  .85 

CHAPTER  Vn. 

Of  the  Developement  of  the  Foetus     .....  89 

CHAPTER  VIII. 

Of  the  Action  of  the  Uterus  ..... 

CHAPTER  IX. 

Of  Displacements  of  the  Uterus          .            ,            .            ■  •            108 

Sect.  I.  Of  Prolapsus  from  Pregnancy     ....  JOS 

II.  Retroversion  of  the  Uterus   .                          .             •  •             109 

III.  Ofthe  Obliquities  ofthe  Uterus                                        •  .118 


103 


CONTENTS. 


CHAPTER  X. 


Of  the  Term  of  Utero-Gcstation 


Cause  of  Labour    . 


CHAPTER  XT. 


CHAPTER  XII. 


Of  Labour        ...••■ 
Sect.  I.  Of  Rigors,  &c.      ..... 

II.  Frequent  inclinations  to  make  water,  Tenesmus,  &c 
in.  Affections  of  the  Uterine  System  in  particular 

a.  Subsiding  of  the  Abdominal  Tumour 

b.  Secretion  of  Mucus     . 

c.  Dilution  of  the  Os  Uteri    . 

a.  Contraction  of  the  Longitudinal  Fibres 

b.  Contraction  of  the  Circular  Fibres 

c.  Of  the  Simple  Contraction     . 

d.  Of  the  Compound  Contraction     . 

e.  Of  the  Tonic  Contraction  and  its  Effects 
/.  Of  the  Spasmodic  or  Alternate  Contraction,  and  its  Effects 

CHAPTER  Xm. 

The  Manner  in  which  the  Os  Uteri  is  opened 

CHAPTER  Xn  . 

Conduct  during  Labour     .  .  • 

Sect.  I.  What  may  be  necessary  for  the  Child 
II.  Unassisted  Dehvery  of  the  Placenta 
HI.  Of  Putting  to  Bed     . 
IV.  Of  After-pams      ... 
"V.  Regimen  during  the  Month,  &c. 
VI.  Of  tl\e  Lochia      .... 

Excessive  Lochia 
Vn.  Attention  necessarj'  to  the  Child 

a.  Of  washing  the  Child 

b.  The  dressing  of  the  Navel 

c.  Purging  off  the  Meconium,  &c.    . 
e?.  Of  the  Retention  of  Urine     . 

Vm.  Of  Food  for  the  Child 


128 


147 


169 
169 
170 
172 
172 
172 
174 
175 
176 
176 
177 
177 
178 


180 


185 
190 
197 
198 
198 
205 
209 
210 
213 
213 
213 
214 
216 
218 


CHAPTER  XV. 

Of  Natural,  or  Unassisted  Labour 


221 


CHAPTER  XVI. 

Of  the  Presentations  of  the  Head 

Sect.  I.  First  Presentation,  and  its  Mechanism  . 

II.  Character  and  Mechanism  of  the  Second  Position 

m. Thu-d  Position 

rV. Fourth  Position 

V.  < Fifth  Position 

VI. Sixth  Position 


224 
226 
227 
227 
228 
233 
233 


PART  II. 

Of  Labours,  in  which  the  child  presents  the  Vertex,  but  rendered  difficult 
or  preternatural     .......  235 


CONTEN'IVS.  VII 

CHAPTEIl  XVll. 

Causes  of  Prenatural  Labours     ......  235 

Sect.  I.  Of  Flooding'              ......  236 

II.  Of  Convulsions  .  .  .  •  •  .238 

III.  Of  Syncopes             .             .             .             .             •         •    .  238 

IV.  Of  Hernia           .             .             .             .             .             .             .  241 

V.  Of  Obliquity  of  the  Uterus                ....  242 

VI.  Of  Partial  Contractions  of  the  Uterus  .  .  .242 

VII.  Of  Compound  Preg-nancy                   ....  247 

VIII.  Of  Prolapsus  of  the  Umbilical  Cord,  &c.            .             .             .  248 

IX.  Of  Too  Short  a  Cord 248 

X.  Of  the  bad  position  of  the  Head,  though  the  Vertex  may  pre- 

sent                  249 

a.  Of  the  Bad  Position  of  the  Vertex                     .             .  249 

b.  Of  the  Chin  departing  too  early  from  the  Breast                .  250 

c.  Cases  in  which  the  Face  Presents         .              .              .  255 

d.  Presentations  of  the  Head  and  Hand           .             .             .  258 

XI.  Of  Exhaustion          ......  260 

XII.  Of  Hemorrhage  from  other  parts  than  the  Uterus       .             .  264 

CHAPTER  XVIII. 

Rules  for  Conducting  a  Preternatural  Labour             .             .             .  265 

Sect.  I.  Position  of  the  Woman  for  Turning        ....  266 

CHAPTER  XIX. 

The  Mode  of  Operating  in  Each  Presentation  of  the  Head                .  272 

Sect.  I.  First  Presentation             ......  272 

II.  Second     do.               ......  273 

III.  Third      do.          ......             .  273 

IV.  Fourth  and  Fifth     do.           ....             .  274 

V.  Sixth                       do.                  .....  275 


PART  III. 

Where  it  is  necessary  to  use  Instruments  which  do  no  injiuy  to  Mother 

or  Child, .277 

CHAPTER  XX. 

Of  the  Forceps             ......  277 

Sect.  I.  General  rules  for  the  use  of  the  Forceps             .             .  .      279 

G,   Of  those  which  regard  the  Woman                   .  279 

6.  Of  the  Condition  of  the  Uterus  and  Soft  Parts  .      280 

c.  Application,  and  mode  of  Action  of  the  Forceps         .  281 
a.  Of  Compression       ......      292 

h.  Compression  and  Traction        ....  294 

d.  Mode  of  Acting  after  Application                .             .  295 
II.  Recapitulation          .             .             .             .             .             .  296 

III.  General  Observations  upon  the  Forceps                        .  .      298 

CHAPTER  XXI. 

Of  the  Specific  Apphcation  of  the  Forceps        .         .             .             .  300 

Sect.  I.  a.  Application  in  the  First  of  these  Positions      .             .  .      301 

II.  h. Second            ....  302 

III.  c. Third                       .             .             .  .303 

IV.  £?. Fourth                          .             .             .  304 

V.  e. ■ Fifth                       .             .  .304 

VI.  /. Sixth               ....  305 

VII.  g. Seventh    .                                       .  .305 


CONTENTS. 


CHAPTER  XXII. 


Cieneral  remarks  on  the  Use  of  the  Forceps,  when  the  Head  is  above  the 

Superior  Strait        .......  306 

CHAPTER  XXin.     * 

Of  the  Locked  or  Impacted  Head              .....  308 

Sect.  I.  Of  the  Causes,  Signs,  and  Accidents  of  the  Locked  Head  309 

n.  Indications  in  the  Locked  Head         ....  309 

HI.  Method  of  using  the  Forceps  in  the  Locked  Head         .            .  311 

CHAPTER  XXIV. 

Of  the  use  of  the  Forceps  in  Face  Presentations        .            .            .  312 
CHAPTER  XXV. 

Of  Presentations  of  the  Breech                  .....  3x5 

Sect.  I.  Species  of  Breech  Presentations        ....  316 

II.  a.  Mechanism  of  First  Breech  Presentations        .             .             .  316 

HI.  b. Second             do.        .         .             .             .  318 

IV.  c. Third                do.           .              .              .              •  ^^^ 

V.  d. Fourth             do.                                           .  318 

CHAPTER  XXVI. 

Causes  which  may  render  Presentations  of  the  Breech  Preternatural  319 

a.  First  degrees  of  Advancement        ....  321 

b.  Second             ditto        .....  322 

c.  Third                ditto               .....  322 
Sect.  I.  Position  of  the  Child              .....  326 

II.  Size  of  the  Breech  .  .  •  .  •  .325 

III.  Mode  of  bringing  down  the  Feet  in  the  first  Breech  Presenta- 
tions              .......  326 

IV.  Mode  in  Second  Position  of  the  Breech               .             .             .  327 
V. Third             ditto      .....  327 

VI. Fourth           ditto                         .             .             .             .  328 

CHAPTER  XXVII. 

On  the  use  of  the  Forceps,  when  the  body  is  delivered,  and  the  head  re- 
tained            .......  329 

Sect.  I.  Cases  proper  for  the  Forceps                  ....  336 

a.  Mode  of  operating  in  First  Case          .             .             .  336 
— Second  do.                .             .             .  338 

CHAPTER  XXVIH. 

Of  the  Presentations  of  the  Feet        .....  338 

Sect.  I.  Species  of  Feet  Presentations                  ....  339 

II.  Preternatural  Labours  when  Feet  present                 .              .  340 

III.  Mode  of  Acting  in  the  First  and  Second  Presentations                .  341 
IV. Third  and  Fourth             do.              .  343 

CHAPTER  XXIX. 

Presentations  of  t!ie  Knees            ......  346 

Sect.  I.  Causes  which  render  Presentations  of  the  Knees  preternatural  347 

II.  Mode  of  Operating  in  Presentations  of  the  Knees           .             .  348 

CHAPTER  XXX. 

Of  Tedious  Labour                 ......  349 

Sect.  I.  Of  the  M^ant  of  Contractile  Force          ....  350 

II.  Of  Rigidity,  &c.  of  the  Soft  Parts,  as  the  cause  of  Tedious  and  pre- 
ternatural Labour             .....  353 


CONTENTS.  IX 

PARE 

Of  the  Species  of  Rigidity  of  the  Os  Uteri              .  .      360 

Rigidity  of  the  first  Kind            ....  360 

V:ir.  1,             .              .             .  .360 

2,  .             .             .             .  361 

3,  .  .  .  .      361 

III.  Cicatrices,  or  other  Imperfections  arising-  from  Local  Injuries,      364 

Relative  Rigidity  .  .         '     .  .  '  .  370 

IV.  Tonic  Rigidity;  or  Rigidity  from  the  Premature  Escape  of  the 

Waters  .......       371 

Sect.  V.  and  VI.  Over-distension  of  tlie  Uterus,  and  the  Membranes  too 

dense,  as  a  cause  of  Tedious  Labour  .  373 

CHAPTER  XXXL 

Hsemorrhage  from  the  situation  of  the  Placenta  over  the  mouth  of  the  Ute- 
rus       .  ........      376 

Sect.  I.  Where  the  Uterus  is  but  little  opened,  and  is  very  rigid  389 

II.  When  but  little  opened,  but  disposed  to  dilate  .  .  392 

III.  Opened  to  some  extent,  but  very  unyielding      .  .  .      393 

IV.  Where  opened  to  the  same  extent,  but  soft  .  .  394 
V.  Where  fully  dilated          .              .              .             .              .              .395 

A  case  of  fiital  Haemorrhage  at  the  Seventh  Month  of  Utero- 
g-estation,  from  the  Placenta  being  placed  over  the  mouth  of 
the  Uterus,  together  with  remarks  upon  it,  and  several  other 
modes  of  treating  Uterine  Hemorrhage  .  .  406 

VI.  Causes  of  Uterine  Inertia  .....      416 

VII.  Haemorrhage,  before  the  Placenta  is  expelled  .  .  416 

a,     I.  Where  there  is  a  partial  separation,  but  the  Uterus  enjoy- 
ing some  tonic  power  .  .  .  .418 
h.  II.  Where  there  is  a  partial  separation,  but  the  Uterus  pos- 
sessing very  little  or  no  tonic  power       .             .  419 

c.  III.  Wliere  thereis  a  partial  separation  of  the  placenta,  while 

the  remaining  portion  is  too  adlierent,  and  the  Uterus 
contracts  but  feebly  ....      423 

d.  IV.  Where  everything  is  as  at  III.  except  that  the  Uterus 

enjoys  its  full  power      ....  426 

e.    V.  Where  there  is  an  entire  or  partial  separation,  but  the 

Uterus  in  a  state  of  exhaustion  or  syncope  .      427 

/.  VI.  Where  there  is  either  a  pai-tial  or  complete  separation  of 

the  placenta,  and  where  the  body  and  fundus  ai-e  in  a 

state  of  Inertia,  wliile  the  neck  enjoys  its  tonic  powers  430 

Vm.  Flooding  after  the  expulsion  of  the  Placenta  .  .  433 

IX.  On  the  means  for  preventing  Flooding  ....      435 

CHAPTER  XXXII. 

Of  the  Assisted  delivery  of  the  Placenta         ....  439 

Sect.  I.  Mode  of  Acting  in  Retention  from  want  of  Tonic  Power  .  440 

II.  Retention  from  too  firm  adherence  ....  440 

a.  Mode  of  acting  in  this  Case  ....  441 

III.  Of  the  Delivery  of  the  Encysted  Placenta     .  .  .  443 

a.  Mode  of  Operating  in  this  Case      ....      445 

IV.  On  the  enclosed  and  partially  protruded  Placenta    .  .  446 

Mode  of  acting  in  each  Case  ....      448 

V.  Of  tlie  delivery  of  the  Placenta,  when  the  cord  is  broken,  or  is  veiy 

feeble         •■....,  449 

a.  The  signs  by  which  the  Placenta  may  be  detected  .      450 

b.  Mode  of  acting  in  this  case        ....  450 

CHAPTER  XXXHI. 

Of  Puerperal  Convul-iions  .  .  .  _  452 

Cases   .........  457 


CONTENTS. 


CHAPTER  XXXIV. 


On  the  Inversion  of  the  Uterus     ......  465 

Cases    .....                         ...  486 

CHAPTER  XXXV. 

Of  Twins,  &:c.               .......  492 

o.  On  the  Management  of  the  Placenta          .             .  502 

CHAPTER  XXXVI. 

Of  Preternatural  labours         ......  505 

CHAPTER  XXXVII. 

Of  the  Presentation  of  the  Arm  and  Shoulder     ....  506 

Sect.  L    Of  the  Condition  of  the  Uterus         ....  512 

II.  Of  the  Situation  of  the  Arm  and  Shoulder  within  the  pelvis       .  5t4 

a.  The  Manner  of  Acting,  jf  the  Child  be  living                .  515 

b.  Of  Spontaneous  Evolution               ....  516 

c.  Mode  of  Actijig,  if  tlie  Child  be  dead               .             .  518 

CHAPTER  XXXVni. 

On  Presentations,  with  the  faUing  down  of  the  Umbilical  Cord   .             .  523 
CHAPTER  XXXIX. 

Of  the  Rupture  of  the  Uterus              .....  535 

Gastj'otomy                ......  545 


PART  IV. 

On  Deliveries  performed  bv  Cutting  Instruments,  applied  either  to  the 
Child  or  Motlier       .  '  .  .  -  .  .  .  548 

CHAPTER  XL. 

Deformity  of  the  Pelvis     .......      548 

Sect.  I.  Of  Turning  in  a  Deformed  Pelvis,  as  a  means  of  saving  the  Child's 

Life 549 

II.  Of  the  Forceps  in  a  Deformed  Pelvis     ....      551 

III.  Of  Cephalotomy        ......  555 

Observations,  &c.,  on  Elizabeth  Sherwood's  Case,  as  related  by 
Dr.  Osborn  ......       566 

IV.  Of  the  Cesarean  Operation  ....  572 

a.  Mode  of  performing  it        .  .  .  .  .  583 

h.  Treatment  after  the  Operation  .  .  .  589 

V.  On  Premature  Delivery  .....  592 

VI.  Section  of  the  Pubes    '.,...  600 

Vn.  Regimen  .......  608 

CHAPTER  XLI. 

Monstrosity  and  Accidental  Deformity  ....  613 

CHAPTER  XLH. 
Uncertainty  of  the  Child's  Death  .  .  .  .  .614 

CHAPTER  XLHI. 
On  the  Secalc  Cornutum,  or  Ergot  .....  615 


INTRODUCTION. 


It  has  often  been  declared,  that  labour,  being  a  natural  act,  ife 
did  not  require  the  interference  of  art  for  either  its  promotion,  or 
its  accomplishment;  and,  consequently,  that  when  this  becomes 
necessary,  it  only  forms  an  exception  to  the  rule.  This  view  of 
the  subject  has  had  many  followers;  and  has,  from  its  influence, 
retarded,  more  perhaps  than  any  other  circumstance,  the  pro- 
gress of  improvement  in  this  most  important  branch  of  medical 
science.  It  so  entirely  comported  with  the  theories  of  the  fasti- 
dious admirers  of  nature;  it  so  completely  coincided  with  the 
feelings  of  those,  whose  supineness  made  them  averse  from  in- 
quiry; so  effectually  apologized  for  ignorance;  and  so  plausibl}'^ 
extenuated  the  evils  arising  from  neglect,  or  the  want  of  the 
proper  and  judicious  application  of  skill,  as  to  secure  in  its 
favour  by  far  the  greatest  portion  of  the  practitioners  of  Mid- 
wifery. 

Errors  in  premises  must  almost  necessarily  lead  to  errors  in  de- 
duction; hence,  the  too  exclusive  reliance  on  the  powers  of  na- 
ture to  overcome  all  the  obstacles  connected  with  parturition — 
hence  the  almost  total  disregard  of  the  first,  and  most  important 
principles  in  the  art  of  midwifery !  These  errors  doubtlessly  ori- 
ginated in  ignorance;  and  were  perhaps  at  first  excusable  from 
this  cause:  but  how  reprehensible  do  they  become  now,  since 
the  powers  of  nature  are  better  calculated,  and  the  resources 
of  art  better  understood!  In  what  light,  then,  should  we  view 
writers,  who  still  inculcate  such  doctrines — teachers  who  make  the 
whole  art  of  midwifery  consist,  in  doing  nothing! 

Were  the  constitutional  powers  of  the  system,  the  physical 
conformation  of  the  pelvis,  and  the  size  of  the  child's  head,  al- 
ways and  undeviatingly  the  same;  were  the  most  favourable  pre- 
sentation of  the  child,  the  best  construction,  and  the  most  healthy 
play  of  the  powers  concerned  in  this  operation,  never  to  be  as- 
sailed by  accident,  or  complicated  by  disease — the  opinions  of 
those  who  contend  for  the  supremacy  of  unassisted  nature,  would 


Xii  INTRODUCTION. 

deserve  much,  and  perhaps  exclusive  attention.  But,  it  is  too 
well  known,  that  this  never  has,  nor  ever  can,  be  the  case;  for 
the  powers  of  nature  must  necessarily  have  their  limits,  and  con- 
sequently the  interference  of  art  becomes  sometimes  absolutely 
necessary. 

I  am  very  far  from  wishing  to  be  understood,  as  advocating 
the  indiscriminate  interference  of  art  during  the  progress  of  a 
healthy  labour — it  is  the  very  reverse  of  my  opinion,  and  of  my 
practice  ;  I  wish  merely  to  insist,  that  nature  is  not  competent  to 
all  exigencies.  For  in  very  many  instances,  when  permitted  to 
proceed  without  interruption,  and  is  eventually  able  to  effect  her 
object,  the  sufferings  of  the  patient,  most  probably,  might  have 
been  ver}'-  much  abridged  by  the  judicious  interposition  of  skill. 
Of  this,  from  long  experience,  I  am  entirely  convinced. 

If  this  be  true  in  the  most  healthy  or  practicable  labour,  how 
much  more  important  does  the  judicious  and  timely  application 
of  adventitious  aid  become,  when  it  is  well  known,  that  the  devi- 
ations from  healthy  power  and  structure,  are  almost  constant  in 
their  occurrence,  and  almost  infinite  in  their  variety.  It  is  the 
knowledge  of  these  aberrations,  and  the  mode  of  obviating  them 
when  necessary,  that  emphatically  declare  midwifery  to  be  a 
science — for  it  has,  and  must  have,  its  principles;  principles,  that 
must  not  only  be  known  in  the  abstract,  but  constantly  employed; 
and  it  is  the  happy  application  of  these  fundamental  rules,  that 
makes  one  practitioner,  superior  to  nnolher. 

I  trust  my  last  assertion  will  not  be  considered  gratuitous;  for 
if  there  be  a  difference  in  the  skill  of  practitioners,  which  most 
certainly  there  is,  it  can  only  arise  from  a  more  perfect  acquaint- 
ance with  the  rules  which  should  govern;  the  extent  of  experi- 
ence; and  the  justness  of  deduction.  But  does  not  this  declare 
there  is  something  more  to  be  learnt,  than  the  bare  exercise  of 
patience?  What  practitioner  has  ever  been  eminentl}'  successful, 
who  has  neglected  the  first  principles  of  the  art?  He  may  be  ex- 
tensively employed,  and  tolerably  lucky,  (for  it  is  nothing  more,) 
without  a  correct  notion  of  either  the  structure  of  tiie  pelvis,  the 
mechanism  of  labour,  or  the  powers  of  the  uterus;  but  will  ho  be 
qualified  to  act  where  the  first  is  faulty;  the  second  obstructed; 
or  the  third  impaired?  will  he  not,  in  most  instances  where 
either  of  these  conditions  obtain,  wait  in  vain  for  the  all-sufficient 
exertions  of  nature? 

Experience,  however  necessary  and  important,  is  not  alone  suf- 


INTRODUCTION.  Xlll 

ficient;  a  correct  foundation  must  be  laid,  by  the  study  of  first 
principles;  and  with  even  these,  the  progress  must  be  slow;  since 
variety  in  labour,  is  so  multiplied.  It  is  only  by  a  happy  and  well- 
balanced  generalization,  that  the  practitioner  can  arrive  at  prin- 
ciples; and  it  is  but  by  judiciously  acting  upon  these,  that  he  can 
be  extensivel}^  useful.  I  may  safely  appeal  to  the  candour  of  al- 
most any  practitioner,  whether  he  has  not  admitted  to  himself,  that 
had  he  been  better  acquainted  with  principles  at  a  previous  pe- 
riod of  practice,  he  could  have  procured,  in  certain  cases  of 
labour,  either  a  speedier  termination  of  it,  or  a  more  fortunate  is- 
sue— I  am  sure  he  will  answer  in  the  alFn-mative. 

Too  much  importance  can  easily  be  attached  to  experience 
alone;  and  though  I  consider  it  a  sine  qua  non  to  the  successful 
exercise  of  the  profession,  yet  it  becomes  only  decidedly  useful 
in  difficult  cases,  when  it  is  based  upon  the  fundamental  principles 
of  obstetrics.  Without  an  acquaintance  with  these,  every  prac- 
titioner must  act  empirically;  and  this  to  the  too  frequent  de- 
struction of  human  life.  If  he  be  ignorant  of  all  that  is  essential 
to  be  known  of  the  well-formed  and  diseased  pelvis;  or  unac- 
quainted with  the  various  ways  the  head  may  pass  through  it,  he 
will  be  totally  incompetent  to  act,  when  there  is  any  material 
deviation  from  the  healthy  economy  of  labour.  On  the  one  hand, 
he  may  rashly  suppose,  there  is  no  alternative  but  in  the  use  of 
the  crotchet,  where  a  little  address  might  have  immediately  re- 
lieved the  patient  by  rectifying  the  error  in  presentation;  and  on 
the  other,  he  may  negligently  and  reprehensibly,  wait  for  the 
successful  operation  of  nature,  until  the  patient  expire. 

In  making  an  estimate  of  the  value  of  experience  alone,  I  must 
admit  that  many  pursue  the  safer  plan  in  submitting  the  case  to 
nature;  for  I  confess  that,  in  many  cases  of  desperate  appear- 
ances, she  successfully  overcomes  the  dangers  that  menace  her; 
but  this  is  only  submitting  to  a  choice  of  evils:  while  the  well-in- 
structed practitioner  would  triumph  over  them  by  his  skill,  and 
spare  nature  this  hazardous  conflict.  That  in  many  instances  we 
should  be  the  silent  observers  of  nature,  is  unhesitatingly  acknow- 
ledged; but  I  must  insist,  and  I  am  persuaded  I  shall  be  supported 
by  every  well-instructed  accoucheur,  that  it  requires  no  less 
judgment  to  determine  when  we  should  be  so,  than  when  it  is 
proper  to  offer  assistance,  or  to  take  the  business  entirely  out  of 
her  hands. 

But  the  decisions  of  ignorance  do  not  always  result  in  an  entire 


xiv  INTRODUCTION. 

reliance  upon  the  powers  of  nature;  they  sometimes,  and  this  but 
too  frequently,  end  in  the  contrary  extreme — in  these  cases,  there 
is,  on  the  part  of  the  practitioner,  an  overweening  desire  to  aid  her 
efforts;  and  his  ill-directed  endeavours,  but  too  soon  eventuate  in 
a  destructive  subversion  of  her  powers.  To  this  we  must  attrib- 
ute the  very  many  instances  of  injury  that  take  place  in  the  hands 
of  the  ill-instructed.  Who  has  not  witnessed  a  labour,  which, 
had  it  been  let  alone,  would  have  been  but  an  ordinary  one,  as 
regards  either  duration  or  severity,  converted  into  one  of  great 
hazard,  and  protracted  duration?  Can  such  mischievous  igno- 
rance be  too  severely  reprehended,  or  could  it  be  too  severely 
punished?  What  has  he  not  to  answer  for,  who  shall  permit  a 
fellow  creature  to  die,  when  a  little  address  or  knowledge  might 
have  saved  her;  or,  what  is  perhaps  still  worse,  who  shall  abso- 
lutely destroy  her,  by  ill-judged  and  rude  manoeuvres,  under  the 
specious  pretence  of  relieving  her,  when  the  case  should  have 
been  trusted  to  the  powers  of  nature  alone. 

Besides,  the  peculiar  situation  of  our  country,  imposes  a  neces- 
sity upon  every  medical  student,  to  become  v.ell  acquainted  with 
the  theory  of  midwifery;  for  every  one  almost  must  practice  it, 
if  he  pursue  the  object  for  which  he  is  educated.  A  change  of 
manners  within  a  few  years,  has  resulted  in  the  almost  exclusive 
employment  of  the  male  practitioner.  Tliis  was  mainly  effected 
by  a  conviction,  that  the  well-instructed  physician  is  better  cal- 
culated to  avert  danger,  and  surmount  difficulties,  than  the  igno- 
rant pretender:  but  how  ill  is  this  confidence  repaid!  a  confidence 
which  costs  the  female,  so  severe  a  struggle!  Should  they  submit 
their  welfare,  nay  their  lives,  to  the  ill-instructed  practitioner, 
what  security  have  they  that  they  shall  escape,  without  having 
entailed  on  them  a  permanent  derangement  of  organ,  or  the  per- 
petuation of  a  harassing,  and  loathsome  disease? 

In  whatever  point  of  view  we  regard  this  subject,  it  must  be 
highly  interesting  to  the  philosopher,  and  the  philanthropist; 
shall  it  be  less  so,  then,  to  the  physician  who  should  be  both, 
and  who  is  more  immediately  concerned  in  its  influence?  Shall 
it  be  a  matter  of  indifference  to  him,  who  has  almost  the  control 
of  the  future  comfort  and  happiness  of  perhaps  an  extensive  pop- 
ulation, and  who  shall  become  as  it  were,  the  arbiter  of  the  lives 
of  thousands?  A  man  of  very  loose  morality  shudders  at  the 
idea  of  a  single  murder;  yet  an  ignorant  practitioner  of  mid- 


INTRODUCTION.  XV 

wifery,  may  feel  no  "  compunctious  visitations  of  conscience"  for 
a  hundred,  committed  professionally,  from  ignorance. 

I  hope  to  be  credited  when  I  declare,  that  the  present  work 
was  not  undertaken,  without  due  deliberation  upon  the  responsi- 
bility attached  to  such  an  enterprise:  and  that  my  aim  most  ho- 
nestly was,  to  be  useful — 1  have  endeavoured  to  make  my  expe- 
rience available  to  the  interests  of  humanity;  and,  should  I  even 
fail  to  instruct,  I  feel  a  confidence,  I  shall  not  dangerously  mis- 
lead. 

I  have  ventured  to  depart  from  common  usage,  in  treating  of 
the  various  objects  belonging  to  my  subject;  but  it  is  the  method 
I  have  pursued  for  more  than  thirty  years  in  teaching;  and  to 
me  it  appears  the  most  natural.  That  is,  to  bring  under  one  view 
all  that  may  belong  to  any  particular  labour,  or  class  of  labours — 
whether  natural,  and  to  be  trusted  to  the  powers  concerned  in 
the  operation ;  or  complicated,  and  requiring  a  departure  from 
this  rule;  or  when  essentially  bad.  I  make  all  the  modes  of 
treating  it  under  the  various  circumstances  which  may  affect  it, 
follow  each  other  without  interruption. 

Generally  speaking,  I  have  followed  Baudelocque's  distribu- 
tion of  subjects,  but  not  rigorously;  and  to  him  I  hold  myself  in- 
debted for  nearly  all  I  know:  or,  at  least,  his  masterly  manner 
of  treating  everything  connected  with  this  branch  of  medicine, 
has  enabled  me  to  comprehend  at  once,  the  seeming  intricacies  of 
obstetrics,  and  to  profit  by  bed-side  experience.  I  therefore  can- 
not too  earnestly  recommend  the  study  of  his  works  to  such  prac- 
titioners, as  well  as  the  student  of  midwifery,  who  may  not  have 
profited  already  by  his  genius,  and  his  long  and  well-tried  ex-r 
perience. 

I  occasionally,  in  the  course  of  the  present  work,  differ  from 
this  great  man,;  but  when  I  do,  it  is  doubtingly;  and  only  when 
a  careful  examination  of  my  own  experience,  has  produced  a  con- 
viction, that  it  is  correct  so  to  do;  accompanied,  however,  at  the 
same  time,  by  a  regret,  that  I  am  forced  to  the  alternative. 

I  have  added  Plates,  to  represent  the  different  positions  of  the 
head,  that  no  embarrassment  might  follow  from  mere  description. 
These  I  hope  will  prove  as  acceptable,  as  I  am  persuaded  they 
will  be  useful. 

I  have  materially  altered  the  arrangement  of  the  present  edi- 
tion, by  removing  from  it  all  the  Chapters  which  related  to  the 
diseases  of  women  and  children.     My  motive  for  this  will  be  ob- 


XVI  INTRODUCTION. 

vious,  when  it  is  recollected,  I  have  written  separate  treatises  on 
both  these  subjects,  since  the  first  publication  of  this  system. 

I  have  also  added  several  very  important  Chapters  on  subjects 
strictly  obstetrical;  together  with  several  new  plates,  illustrative 
of  the  topics  to  which  they  have  reference.  In  a  word,  I  have 
attempted  to  make  this  present  edition,  deserving  of  the  high  pa- 
tronage this  work  continues  to  receive. 


COMPENDIOUS  SYSTEM 


MIDWIFERY, 


CHAPTER  I. 
Section  I. — Of  the  Pelvis. 

1.  The  complete  knowledge  of  the  pelvis,  as  well  in  its 
healthy  as  in  its  diseased  state,  is  essentially  necessary  to  the 
successful  practice  of  midwifery.  Had  more  attention  been  paid 
to  acquiring  an  acquaintance  with  its  natural,  and  its  deranged 
dimensions  by  those  who  profess  to  practise  this  important 
branch  of  medicine,  we  should  have  had  fewer  instances  of  gross 
mistakes,  and,  of  course,  fewer  victims.  Without  understanding 
the  pelvis  well,  it  is  impossible  that  any  one  can  safely  give 
assistance  where  either  the  operation  of  turning,  or  the  applica- 
tion of  the  forceps,  is  required,  to  terminate  the  labour;  nor  can 
the  mechanisms  of  the  various  presentations  be  understood  in 
their  most  simple  forms,  without  a  thorough  knowledge  of  it. 
We  hope  then  we  shall  be  excused  when  we  say,  that  no  man 
should  be  trusted  to  practise  obstetrics,  who  is  ignorant  of  this 
important  assemblage  of  bones. 

2.  The  pelvis  is  that  structure  which  is  situated  below  the 
last  lumbar  vertebra,  with  which  it  is  by  one  of  its  surfaces 
articulated  ;  and  above  the  superior  extremities  of  the  thigh 
bones,  with  which  it  is  connected,  by  means  of  the  acetabula. 
It  is  composed,  properly,  but  of  four  bones  in  the  adult  state, 
viz.  on  its  posterior  and  inferior  part,  by  tlie  sacrum  and  coccyx ; 
and  on  the  lateral  inferior  and  anterior  parts,  by  the  ossa  inno- 
minata.     But  in  treating  of  this  structure,  it  is  useful  and  proper, 

3 


18  THE  SACRUM. 

to  consider  its  constituent  parts,  as  eacii  is  composed  of  several 
others,  to  which  appropriate  divisions  and  names  have  been 
given;  we  shall  therefore  pursue  this  plan,  as  it  has  both  pro- 
priety and  utility  to  recommend  it;  and  first,  of 

Sect.  II.  —  The  Sacrum. 

3.  This  bone  has  been  sometimes  called  the  false  vertebrae, 
because  it  is  a  kind  of  continuation  of  the  true;  and  because,  in 
the  foetal  state,  it  may  be  divided  into  five  portions.  The  union 
of  these  five  pieces  can  readily  be  detected  in  adult  age,  b}^  four 
transverse  seams.  *  Its  general  figure  is  triangular  or  pyramidal ; 
the  base  of  which  is  upwards,  and  is  connected  to  the  last  lumbar 
vertebra,  by  a  cartilaginous  intervention.  The  apex  of  the 
triangle  or  pyramid  is  below;  and  has  the  coccyx  united  to  its 
extremity,  by  means  of  cartilage.  It  may  be  divided  into  four 
surfaces;  namely,  an  anterior,  posterior,  and  two  lateral  surfaces: 
its  anterior  surface  is  smooth  and  concave;  while  its  posterior 
is  very  rough  and  convex;  its  anterior  face  is  smooth,  that  no 
obstacles  may  be  offered,  or  abrasions  take  place,  by  the  passage 
of  the  child's  head  through  the  cavity  of  the  pelvis;  its  posterior 
is  studded  with  processes  or  eminences,  to  give  greater  security 
and  surface  to  the  various  muscles  that  originate,  and  that  are 
inserted  on  it;  as  also,  to  afford  greater  firmness  of  connexion 
to  the  many  ligaments  which  aid  in  its  union  with  the  ossa  inno- 
minata.  Its  lateral  surfaces  are  rough  or  scabrous;  and  are 
covered  in  the  recent  subject  with  cartilage,  by  means  of  which 
they  are  united  to  corresponding  surfaces,  offered  by  the  ilia. 
This  bone  is  pierced  on  each  side  by  four  holes,  which  transmit 
the  sacral  nerves.  There  is  also  on  its  posterior  portion,  a  canal, 
along  which  the  spinal  marrow  is  continued. 

4.  The  manner  in  which  the  sacrum  is  set  into  the  ossa  inno- 
minata,  is  well  calculated  to  give  firmness  and  security  to  its 

•  Velpcau  speaks  doubtingly  of  the  number  of  pieces  and  lines  in  which  the 
sacrum  may  be  divided — why,  we  are  at  a  loss  to  understand,  as  our  impression 
is,  that  nature  is  uniform  in  tliis  respect.  He  says,  "sa  face  (the  sacrum)  anter- 
cure,  plus  ou  moins  concave,  offre,  au  milieu,  quatre  on  cinqfacettcs  qiiadrangu- 
laires  et  uutant  de  Ugnes  transversales."  p.  3.  Baudelocque  makes  but  four  lines, 
as  it  requii-es  five  pieces  to  give  four  lines  when  united.  He  makes  but  four 
holes  for  the  transmission  of  the  sacral  nerves,  whereas  Velpeau  makes  five.  It 
is  true,  that  tlie  upper  portion  of  tlie  coccyx  unites  witli  tlie  inferior  portion  of 
the  sacrum,  and  thus  forms  an  additional  hole.  In  general,  however,  tliis  is 
merely  a  notch  in  each  of  these  bones,  forming  thus  an  imperfect  foramen,  for 
the  transmission  of  the  fifth  nerve  of  the  sacrum;  but  this  hole  is  not  proper 
i  o  the  sacrum. 


THE  COCCYX.  19 

position;  as  it  acts,  in  some  measure,  as  a  key-stone  does  to  an 
arch:  this  arises  from  two  peculiarities  of  form:  the  anterior  part 
of  this  bone  is  broader  than  the  posterior;  consequently,  enters 
like  a  wedge  between  the  ossa  innominata;  this  enables  it  to 
sustain  without  injury,  any  foi'ce  that  may  operate  from  within, 
outwards:  the  superior  portion  is  also  broader  than  the  inferior; 
and  of  course  is  placed  precisely  analogous  to  the  key-stone  of 
an  arch,  by  which  it  is  enabled  to  support  the  superincumbent 
weight  of  the  body,  &c.  without  yielding.  We  cannot  fail  to 
remark,  how  admirably  this  arrangement  gives  stability  to  the 
whole  of  the  pelvic  circle. 

5.  The  union  of  the  last  lumbar  vertebra  with  the  base  of  the 
sacrum,  is  permitted  to  take, place  in  such  a  manner  as  to  look 
over,  and  into,  the  superior  opening  of  the  pelvis,  so  as  to  form 
a  promontory;  and  hence,  it  is  called  the  projection  or  promon- 
tory of  the  sacrum. 

6.  The  length  of  this  bone  is  usually  from  four  inches,  to  four 
and  a  half;  its  breadth  is  about  four  inches.  Its  thickness,  if 
measured  from  the  middle  of  its  base  anteriorly,  to  the  extremity 
of  the  superior  spinous  tubercle  on  its  posterior  face,  is  very 
constantly  two  inches  and  a  half;  and  we  are  informed  by  Bau- 
delocque,*  that  this  measurement  is  so  constant,  that  he  did  not 
find  it  vary  a  line  in  between  thirty  and  forty  pelves,  the  greater 
part  of  which  were  deformed.  The  concave  form  of  this  bone 
gives  a  hollowness  to  a  greater  part  of  its  length;  the  depth  of 
this  in  a  well  formed  bone  is  about  three  quarters  of  an  inch. 

Sect.  III. —  The  Coccyx. 

7.  This  appendage  to  the  sacrum  is  also  of  a  pyramidical 
form,  and  is  about  an  inch  and  a  quarter  in  length;  like  the  sa- 
crum itself,  it  resembles  an  inverted  pyramid;  its  bass  being 
united  with  this  bone  by  intervening  cartilage:  it  is  formed  of 
three  bony  portions,  whose  connexion  with  each  other  is  readi- 
ly observed  by  the  transverse  ridges  which  their  union  forms. 
Its  connexion  is  such,  as  to  permit  of  a  regressive  motion;  es- 
pecially in  the  earlier  parts  of  life.  Lateral  motion  is  prevented 
by  the  insertion  into  the  sides  of  this  bone,  of  the  coccygaei 
muscles;  of  parts  of  the  levatores  ani;  and  portions  of  the  sacro- 
sciatic  ligaments. 

*  System,  page  18,  par,  35. 


20  THE  OSSA  INNOMINATA. 

Sect.  IV. — The  Ossa  Innominata. 

8.  The  other  portions  of  the  pelvis  are  made  up  of  the  ossa 
innominata;  they  constitute  the  lateral,  anterior,  and  inferior 
parts  of  this  cavity.  Each  of  these  is  divided  into  three  distinct 
bones  by  all  the  writers  upon  midwifery  or  anatomy;  and  there 
seems  to  be  propriety  in  this  separation;  since  they  were  origi- 
nally, or  in  the  foetal  state,  distinctly  marked  as  independent 
bones,  though  not  so  clearly  defined,  in  adult  life;  and  in  the 
study  of  the  pelvis,  it  will  contribute  to  a  more  precise  notion  of 
its  form  and  combinations.  The  os  innominatum  is  then  com- 
posed of  the  ilium,  ischium,  and  pubis. 

9.  The  iha  form  the  highest  lateral  portions  of  the  pelvis;  and 
may  with  much  propriety  be  considered  as  belonging  to,  and 
constituting  a  part  of  the  abdomen,  as  well  as  of  the  pelvis  pro- 
perly so  called;  the  ilium  is  the  largest  of  the  bones  now  under 
consideration — its  superior  edge  is  nearly  semicircular,  and  is 
almost  always  tipped  with  cartilage;  this  is  called  the  spine  of 
the  ilium.  It  reaches  down,  and  forms,  with  certain  portions  of 
the  ischium  and  pubis,  the  acetabulum.  The  external  surface  of 
this  bone  is  a  little  convex,  and  has  been  named  dorsum;  while 
its  internal  face  is  concave,  and  is  called  costa,  or  fossa  of  the  ilium. 
There  are  four  processes  usually  described  as  belonging  to  the 
ilium;  namely,  two  anterior,  and  two  posterior,  spinous  processes. 

10.  The  broad,  spreading  part  of  this  bone  is  divided  from  the 
lower  portions,  by  a  ridge  which  commences  at  its  connexion 
with  the  sacrum;  runs  forward,  and  joins  with  a  similar  ridge, 
sent  by  the  os  pubis — this  sliarp  line  marks  the  upper,  from  the 
lower  boundary  of  the  pelvis;  and  is  called  the  linea  ilio  pectinea. 

11.  The  ischium  is  the  lowest  of  the  three  bones;  and,  like 
the  ilium,  forms  a  part  of  the  acetabulum.  From  the  posterior 
part  of  this  bone,  a  sharp  process  runs  backward,  yet  inclining 
towards  the  cavity  of  the  pelvis,  so  as  rather  to  diminish  its  ca- 
pacity; to  this  is  attached,  the  internal  sacro-sciatic  ligaments; 
it  then  runs  downward,  and  terminates  in  a  tuber;  into  the  in- 
side of  which,  the  external  sacro-sciatic  ligament  is  affixed. 
From  this  tuber  a  bony  process  is  reflected,  which  joins  the  os 
pubis. 

12.  The  OS  pubis  is  the  smallest  of  the  three  bones  which  con- 
stitute the  OS  innominatum — its  largest  portion  is  employed  in 
the  formation  of  the  acetabulum;  it  then  diminishes  in  size;  and 
stretches  over,  to  meet  a  similar  portion  of  the  os  pubis  of  the 


OF  THE  SEPARATION  OF  THE  BONES  OF  THE  PELVIS.  21 

opposite  side.  It  now  becomes  broader  and  thinner,  and  sends 
a  branch  downwards,  to  unite  with  the  one  reflected  from  the 
OS  ischium.  The  mode  of  union  of  these  bones  is  such,  as  to 
leave  a  considerable  space  between  them,  and  this  space  is  call- 
ed, foramen  ovale,  or  foramen  magnum  ischii ;.  which  in  the  recent 
subject,  is  covered  by  a  dense  ligamentous  membrane,  and  gives 
origin  to  the  obturator  muscles.  Nerves  and  blood-vessels  are 
transmitted  through  this  membrane,  by  appropriate  openings. 

13.  The  ossa  innominata  are  joined  at  their  posterior,  and 
central  portions,  to  the  sacrum,  by  rough  corresponding  surfaces; 
these  are  spread  over  by  thin  cartilage;  and  the  union  secured 
by  strong  appropriate  ligaments.  The  anterior  junction  of  these 
bones  is  called  the  symphysis  of  the  ossa  pubis;  but  the  mode  of 
union  is  different  from  that  which  connects  their  posterior  por- 
tions— agreeably  to  Baudelocque,  nature  has  paid  much  more 
attention  to  it,  than  to  the  other  parts  of  the  pelvis,  by  sending 
out,  in  addition  to  a  proper  quantity  of  cartilage,  a  number  of 
short,  but  very  strong  ligaments,  which  give  great  security  to 
the  symphysis.  Dr.  Wm.  Hunter  has  also  given  a  very  particular 
description  of  the  mode  of  union  of  this  symphysis,  in  the  second 
volume  of  the  Medical  Observations  and  Inquiries. 

14.  As  it  is  not  in  the  power  of  everybody  to  consult,  and 
study  the  pelvis  from  the  natural  one,  it  is  thought  important  to 
give  a  figure  of  a  healthy,  well  constructed  one;  that  an  idea  may 
be  formed  of  its  general  shape  and  connexions;  and  though  not 
as  satisfactory  as  the  natural  preparation,  it  will  nevertheless  give  a 
pretty  correct  notion  of  it.     (See  Plates  I.  and  II. ) 

Sect.  V. — Of  the  Separation  of  the  Bones  of  the  Pelvis. 

15.  It  would  seem,  from  what  occasionally  occurs  in  practice, 
that  the  bones  of  the  pelvis  may  separate,  notwithstanding  the 
especial  care  that  nature  has  bestowed  upon  their  union.  This 
separation  may  take  place  in  various  degrees:  from  a  simple 
relaxation  of  the  connecting  media,  to  an  absolute  separation. 
This  accident  may  happen  gradually;  commencing  almost  with 
gestation,  but  not  manifesting  itself  with  much  severity  until  after 
delivery;  or  it  may  occur  suddenly  during  labour;  or  just  when 
it  is  about  to  be  finished.  Fortunately  for  the  female,  it  is  a 
disease  of  rare  occurrence;  at  least  in  this  country;  for  we  have 
met  with  but  two  decided  cases  of  the  kind  in  the  course  of  our 
practice. 


22  OF  THE  SEPARATION  OP  THE  BONES  OP  THE  PELVIS. 

16.  Were  we  to  yield  to  popular  belief,  we  should  be  obliged 
to  grant,  that  nature  had  kindly  studied  the  comfort  and  safety 
of  the  female,  by  endowing  the  ligaments  and  cartilages  which 
connect  the  different  portions  of  the  pelvis  with  a  capacity  to 
yield  to  the  impulses  of  labour,  that  the  operation  might  not 
only  be  less  severe,  but  safer.  This  opinion  is  coeval  with 
medical  record,  and  it  has  been  sustained,  not  only  by  ingenious 
reasoning,  but  by  an  appeal  to  observation.  The  respectable 
names  of  Pineau  and  Pare  are  used  in  support  of  it  among  the 
more  remote  moderns;  and  Gardien,  in  our  own  time,  yields  to 
a  belief  of  its  advantage.  While  Baudelocque,  Denman,  &c.  see 
nothing  in  this  supposed  provision,  but  misery  to  the  female  who 
may  be  the  subject  of  it. 

17.  We  may  adduce  the  following  reasons  as  conclusive 
against  this  relaxation  being  a  natural  provision — 1.  It  is  certain, 
so  far  as  can  be  determined  by  the  dissection  of  women  who  had 
died  during,  or  immediately  after  labour,  that  the  symphyses 
were  very  rarely  found  to  have  yielded  in  the  slightest  degree. 
Baudelocque  tells  us,  he  sought  for  it  twenty  times  in  well- 
constructed  pelves  after  laborious  labours,  as  well  as  in  distorted 
ones,  without  meeting  with  scarcely  one,  which  could  remove 
all  doubts  of  its  existence.*  2.  That  it  is  not  more  frequent  in 
the  distorted,  than  in  the  well-formed  pelvis;  now,  were  it  an 
advantageous  provision,  it  consequently  should  have  been  more 
certainly  observed  in  the  former.  3.  Were  it  an  arrangement 
of  nature,  the  means  do  not  seem  adequate  to  the  end;  as  it 
would  require  that  the  extremities  of  the  ossa  pubis  should  be 
separated  one  inch  from  each  other,  to  gain  two  lines,  or  two- 
twelfths  of  an  inch,  in  the  antero-posterior  diameter  of  the 
superior  strait;  an  increase  but  very  rarely  sufficient  to  do  good 
in  a  contracted  pelvis;  and  unnecessary  in  a  well-formed  one ; 
as  the  latter  is  almost  constantly  larger  than  is  absolutely  neces- 
sary in  ordinary  labours.  4.  That  wherever  it  has  been  ascer- 
tained to  have  taken  place  even  in  a  slight  degree,  it  has  never 
failed  to  create  either  temporary,  or  a  permanent  inconvenience; 
and,  where  extensive,  the  most  serious  evils,  and  even  death, 
have  followed. 

IS.  Various  causes  have  been  assigned  for  this  relaxation  or 
separation  of  the  pelvic  bones:    1.   Serous  depositions  in  the 

*   System,  vol.  i.  pur.  55. 


OP  THE  SEPARATION  OP  THE  BONES  OP  THE  PELVIS.  23 

cellular  meshes,  or  interstices  of  the  connecting  media.  2, 
Tumefaction  of  the  cartilaginous  extremities  of  the  ossa  pubis. 
3.  The  child  in  transitu  acting  like  a  wedge  on  the  bony  circle 
which  bounds  the  upper  strait.  4.  Mechanical  violences,  as 
falls,  blows,  instrumental  delivery,  &c. 

19.  When  mere  relaxation  exists,  the  symptoms,  though  pretty 
permanent,  are  not  so  violent,  as  when  there  is  a  separation.  A 
painful  tottering  walk,  with  a  greater  or  less  inability  to  stand, 
and  more  especially  on  both  feet  with  equal  firmness,  mark  very 
certainly  this  condition  of  the  pelvis;  and  this  is  sometimes 
detected  even  before  labour.  When  it  happens  during  labour,  it 
is  always  attended  with  a  painful  sensation  at  the  relaxed  part, 
together  with  an  inability  to  exercise  the  auxiliary  powers  con- 
cerned in  this  operation.  This  latter  circumstance  is  worthy  of 
notice;  as  it  would  seem  to  decide  at  once,  that  this  yielding  is 
not  intended  to  benefit  parturient  women.  When  the  injury  is 
greater,  and  a  real  separation  has  taken  place,  it  has  been  found, 
that  it  is  by  the  destruction  of  the  ligamentous  tissue  which 
connects  the  bones,  and  thus  permits  them  to  retire  further  from 
each  other  than  mere  relaxation  would  have  done.  When  it  is 
the  symphysis  of  the  pubes  which  suffers  this  accident,  an  entire 
separation  of  the  cartilaginous  epiphysis  from  the  extremity  of 
the  OS  pubis  takes  place;  for  agreeably  to  Baudelocque,  no 
power  is  capable  of  breaking  the  ligamentous  substance  which 
connects  these  two  bones. 

20.  When  this  last  condition  obtains,  it  is  usually  followed  by 
a  melancholy  train  of  evils— pain,  inflammation,  suppuration, 
caries,  gangrene,  and  death. 

21.  The  mode  of  treatment  of  these  evils  is  reduced  to  great 
simplicity,  though  far  from  equal  certainty— the  indications  are: 
1.  To  reduce  the  parts  as  nearly  as  possible  to  their  natural  po- 
sition, and  to  secure  them  thus  as  effectually  as  possible.  2.  To 
obviate  inflammation  and  its  consequences,  as  far  as  may  be 
practicable.  3.  To  relieve  pain.  4.  To  give  strength  at  a  proper 
time  to  the  system  generally. 

.  22.  The  first  indication  must  be  fulfilled  by  the  proper 
application  of  bandages;  and  we  are  of  opinion,  that  the  simple 
calico  roller  is  as  effectual  as  any  of  the  more  complicated 
machinery  contrived  for  this  purpose.  It  should  be  applied  as 
high  as  the  cristas  of  the  ilia,  and  a  little  below  the  trochanters 


24    OF  THE  SEPARATION  OF  THE  BONES  OF  THE  PELVIS. 

of  the  thio-hs — its  length  should  be  so  ample,  as  to  secure  a  num- 
ber of  turns  round  the  parts;  and  it  should  be  drawn  sufficiently 
tight  to  fulfil  the  object  for  which  it  is  applied.  The  patient 
must  be  confined  to  a  horizontal  position,  and  employ  her  lower 
extremities  as  little  as  possible,  at  least  in  the  beginning  of  the 
plan. 

23.  The  second  indication  must  be  answered  by  blood-letting, 
leeching,  or  cupping;  a  very  abstemious  vegetable  diet  must  be 
insisted  on;  and  the  most  perfect  quiet  observed;  the  bowels 
should  be  kept  free,  but  the  effects  of  brisk  purging  must  be 
doubtful — this  plan  should  be  persisted  in,  until  fever  is  subdued; 
then  the  course  may  be  changed  as  in  any  other  case,  to  a  more 
generous  diet,  or  invigorating  regimen.  If  it  run  on  to  suppura- 
tion, it  must  be  treated  throughout  its  consequences,  as  any  other 
abscess  should  be. 

24.  The  third  indication  must  be  fulfilled  by  the  proper  exhi- 
bition of  opium,  in  its  various  forms. 

25.  The  fourth  must  be  complied  with,  by  the  judicious  ad- 
ministration of  tonics;  as  bark,  sulphate  of  quinine,  &c.  &c.  and 
by  the  daily  use  of  the  cold  bath,  where  there  are  no  contraindi- 
cations to  render  its  use  improper. 

26.  I  believe  I  am  justified  in  saying,  that  women  may  very 
effectually  recover,  when  the  symphyses  have  suffered  from 
mere  relaxation  of  their  ligaments;  but  I  fear  we  have  but  little 
reason  to  hope  for  an  effectual  cure,  when  the  bones  have  been 
denuded  of  their  cartilages,  though  the  situation  of  the  woman, 
by  proper  treatment,  may  be  made  comparatively  comfortable. 

27.  As  the  derangements  either  of  separation,  or  of  relaxation, 
of  the  pelvic  symphyses  are  of  very  rare  occurrence,  I  hope  I 
shall  be  excused,  for  giving  at  length  the  cases  communicated  by 
Dr.  A.  J.  Nicholson,  in  "  Vol.  iv.  p.  452,  of  the  Transactions  of 
the  Association  of  Fellows  and  Licentiates  of  the  King  and 
Queen's  College  of  Physicians,  in  Ireland. 

28.  Dr.  N.  says,  "  It  appears  from  the  extensive  observations 
of  the  most  eminent  accoucheurs  in  Paris,  Vienna,  and  Dublin, 
that  this  disease  is  of  rare  occurrence.  In  the  following  case, 
the  woman,  after  a  natural  delivery,  did  well  to  the  fourth  day, 
when  she  complained  of  an  inability  of  moving  her  limbs. 

29.  "  On  making  inquiry,  she  informed  me,  that  while  at  the 
fire  she  felt  sick,  and  fell  off  the  low  seat  on  which  she  was  sit- 


OP  THE  SEPARATION  OF  THE  BONES  OF  THE  PELVIS.  25 

ting.  The  nurse  tender  had  left  her,  and  when  she  returned  she 
found  her  fainting  on  the  floor.  When  she  recovered  she  was 
quite  unable  to  afford  herself  any  assistance. 

30.  "  In  the  course  of  the  fifth  day  she  was  seized  with  fre- 
quent rigours,  so  violent  as  to  shake  the  entire  bed;  and  she 
complained  of  excruciating  pain  at  the  end  of  the  os  pubis,  and 
along  the  course  of  the  left  thigh.  The  fainting  and  rigours  re- 
turned to  such  an  excess,  that  I  found  it  necessary  to  remain 
with  her.  Wine  and  other  stimulants  were  given,  which  soon 
alleviated  these  distressing  symptoms.  Her  stomach,  however, 
was  at  times  much  disturbed;  and  she  was  tormented  with  noise 
in  her  ears,  and  constant  sneezing,  which  greatly  aggravated  the 
pain  at  the  pelvis. 

31.  "To  relieve  these  unpleasant  sensations,  she  took  the 
black  drop  in  large  doses,  which  agreed  extremely  well  with 
her.  I  at  first  tried  opium,  but  it  caused  very  unpleasant  sensa- 
tions when  she  closed  her  eyes,  and  kept  her  in  a  constant  state 
of  terror. 

32.  "  On  putting  the  finger  over  the  symphysis,  at  its  edge  cre- 
pitation was  distinctly  perceived;  a  tumour  was  also  observed  on 
each  side  of  the  sacrum  on  examining  it  particularly  ;  the  tumour 
was  hard  and  circumscribed,  and  about  the  size  of  a  hazel-nut. 

33.  "  Whenever  she  was  moved,  the  pain  was  so  agonizing, 
that  she  said  they  must  be  tearing  her  asunder.  I  communicated 
to  the  family  my  opinion,  that  the  ossa  pubis  had  separated,  and 
requested  a  consultation.  In  the  mean  time,  I  ordered  her  to 
be  kept  in  a  state  of  rest,  and  applied  a  firm  broad  bandage 
around  the  pelvis,  from  which  she  experienced  the  greatest  relief, 
and  found  herself  more  comfortable  than  any  time  since  her  con- 
finement. A  solution  of  muriate  of  ammonia  was  applied  to  the 
tumours  on  the  sacrum:  they  did  not  cause  any  considerable  in- 
convenience, and  were  soon  removed. 

34.  "  For  nearly  six  weeks  she  remained  perfectly  well  in  her 
health,  and  easy  in  her  bed,  except  when  she  attempted  to  move 
or  turn  on  either  side,  on  which  occasion  she  always  suffered  the 
most  violent  pain.  She  could  stretch  her  feet  downwards,  but 
could  not  draw  them  up  again;  she  found  relief  from  leaning 
forwards,  and  placing  her  elbows  on  her  knees;  and  when  that 
position  became  irksome,  she  returned  to  her  usual  one  on  her 
back,  when  she  always  felt  easy.     About  this  time  she  men- 

4 


26  OF  THE  SEPARATION  OF  THE  BONES  OF  THE  PELVIS. 

struated,  and  though  much  benefit  was  expected  from  this  cir- 
cumstance, yet  no  alteration  took  pltice  in  her  complaint. 

35.  "  A  gentleman  of  considerable  experience  in  midwifery, 
{Dr.  Beatty,)  saw  her  in  about  ten  weeks  from  her  confinement; 
and,  after  a  very  careful  examination,  we  found  the  internal  parts 
in  their  natural  situation,  and  free  from  disease.  The  perinseum 
was  not  lacerated,  nor  was  there  the  least  appearance  of  injury 
about  the  external  parts ;  but  on  considering  the  seat  of  the  pain, 
and  the  inability  of  moving  her  limbs,  there  could  be  no  doubt 
that  the  symphysis  of  the  ossa  pubis  had  separated.  The  broad 
bandage  was  continued,  with  cold  applications  to  the  seat  of  the 
pain.  A  bandage,  to  keep  the  knees  together,  was  also  suggested 
by  Dr.  Beatty,  and  adopted. 

36.  "  In  the  course  of  conversation,  after  it  continued  for  five 
months,  the  circumstance  was  related  to  a  medical  friend,  who 
stated  that  he  had  a  case  somewhat  similar,  though  more  aggra- 
vated, a  few  years  before. 

37.  "In  that  instance  it  appeared  that  for  several  days  before 
labour  came  on,  she  suffered  much  from  pain  and  weakness  in 
her  back,  and  a  total  inability  of  moving  herself,  which  caused 
her  labour  to  be  unusually  severe,  as  she  was  unable  to  render 
herself  any  assistance.  A  crackling  noise  could  be  distinctly 
heard  at  several  yards  distance,  and  not  only  were  the  pelvis 
and  sacrum  separated,  but  the  disease  seemed  to  have  extended 
to  the  functions  of  all  the  bones  of  the  pelvis. 

38.  "Many  medical  men  of  eminence  were  consulted,  and 
a  variety  of  medicines  were  exhibited.  Bark,  wine,  muriate  of 
lime,  carbonate  of  iron,  tincture  of  iron,  and  every  other  remedy 
that  could  be  thought  of.  At  the  end  of  seven  months  no  improve- 
ment whatever  had  taken  place,  and  her  situation  being  truly 
deplorable,  he  determined  on  using  the  shower-bath,  the  good 
effects  of  which  were  soon  apparent;  for  in  a  few  weeks  she  was 
able  to  walk  on  crutches  about  the  room,  and  in  two  months  to 
go  up  stairs,  which  to  a  person  so  affected,  was  an  operation  of 
no  little  diificulty.  In  three  months  she  was  fully  restored  to 
the  use  of  her  limbs,  and  has  had  a  living  child  after  a  tedious 
but  natural  birth. 

39.  "  I  immediately  communicated  the  result  of  this  case  to 
my  patient,  who  agreed  to  do  willingly  whatever  I  proposed. 
A  partial  shower-bath  was  contrived;  and  before  the  expiration 
of  a  month,  not  only  great  relief  from  pain,  but  much  benefit 


OP  THE  SEPARATION  OP  THE  BONES  OP  THE  PELVIS.  27 

was  experienced;  for  she  was  once  more  able  to  pull  on  her 
stockings,  and  draw  up  her  feet. 

40.  "  About  two  months  after,  she  expressed  a  great  inclination 
to  try  to  walk,  which  I  have  often  since  regretted  was  not  agreed 
to.  She  continued,  however,  free  from  pain,  and  in  good  health 
until  December,  (just  twelve  months  from  her  confinement,) 
when,  contrary  to  my  wish  and  opinion,  she  was  moved  to  her 
husband's  house,  as  she  had  been  confined  at  her  father's. 

41.  "  She  was  put  into  a  chaise,  but  whether  from  the  motion 
of  the  carriage,  or  the  confinement  in  which  she  was  obliged  to 
be  in,  during  two  hours,  I  cannot  say,  but  all  the  unpleasant 
symptoms  returned,  accompanied  with  great  pain,  and  the 
crackling  of  the  pubis. 

42.  "  At  this  period  I  gave  up  my  attendance,  as  I  did  not  ap- 
prove of  the  proceeding.  She  was  put  under  the  care  of  another 
practitioner,  who,  I  understand,  employed  counter-extension,  to 
keep,  as  he  termed  it,  <  the  opposite  sides  of  the  pelvis  in  oppo- 
sition.' This  was  contrived  by  keeping  her  upper  and  lower 
extremities  fastened  to  the  bed-post;  but  it  caused  such  jDain,  that 
she  refused  to  endure  it  any  longer:  and  matters  having  become 
much  worse,  I  was  requested  to  renew  my  attendance.  I  found 
her  quite  resigned  to  her  situation,  but  without  any  hopes  of  re- 
covery, to  which  she  had  so  patiently  looked  forward.  I  per- 
suaded her  to  return  to  the  constant  use  of  the  shower-bath  and 
belt,  both  of  which  had  been  much  neglected. 

43.  <'I  visited  her  at  Easter,  and  staid  with  her  two  days;  and 
was  satisfied  from  close  observation,  that  she  was  in  a  fair  way 
of  recovery.  She  was  playing  with  her  child  on  the  bed,  and 
she  turned  herself  in  various  directions  without  making  any 
complaint;  and  her  sister,  who  slept  with  her,  told  me  that  she 
had  often  turned  on  her  side  in  her  sleep,  without  experiencing 
any  bad  effect  the  next  morning.  I  contrived  a  little  carriage 
for  her,  in  which  she  could  lie  lengthways,  and  which  was  easily 
wheeled  about  the  garden.  The  delightful  sensation  she  expe- 
rienced on  once  more  breathing  the  fresh  air,  after  being  confined 
nearly  eighteen  months,  may  be  readily  conceived.  A  pair  of 
crutches  were  procured,  and  directions  given,  if  she  should  have 
any  inclination  to  stand  or  walk,  to  allow  her  to  make  a  trial. 

44.  '-1  had  a  letter  from  her  about  a  month  ago,  in  which  she 
gave  me  the  pleasing  intelligence,  that  she  had  either  walked,  or 
shufiled  half  across  the  room,  and  felt  no  pain  from  the  exertion; 


28  OF  DEFORMITY  OF  THE  PELVIS. 

and  every  subsequent  account  confirms  the  pleasing  prospect  of 
her  complete  recovery." 

Sect.  VI. — Of  Deformity  of  the  Pelvis. 

45.  Every  departure  from  the  healthy  dimensions  of  a  pelvis, 
either  by  excess  or  diminution,  is  considered  a  deformity — I 
shall  therefore  first  state  the  admeasurements  of  the  different  por- 
tions of  this  cavity,  as  generally  agreed  upon  by  writers,  before 
I  proceed  to  the  consideration  of  such  alterations  as  may  justly 
be  considered  as  deformities. 

46.  The  diameter  which  runs  from  the  superior  part  of  the 
symphysis  of  the  pubes  to  the  projection  of  the  sacrum,  in  a 
well-formed  pelvis,  is  rather  more  than  four  inches;  while  the 
one  running  from  side  to  side,  a  little  exceeds  five  inchesj  and 
the  one  traversing  the  pelvis  diagonally,  from  behind  one  of  the 
acetabula  to  the  union  of  the  os  innominatum  with  the  sacrum,  is 
nearly  the  same.  The  first  of  these  is  called  the  antero-posterior 
diameter,  or  small  diameter  of  the  superior  strait;  the  second, 
the  transversal  or  great  diameter;  and  the  third,  the  oblique, 
which  is  also  properly  considered  the  great  diameter.  At  the 
inferior  part  of  the  pelvis,  or  the  lower  strait,  the  measurements 
are  nearly  the  same,  but  reversed — that  is,  the  great  diameter  of 
this  strait  runs  from  the  inferior  edge  of  the  symphysis  pubis, 
to  the  point  of  the  coccyx,  allowing  for  the  regressive  power  of 
this  bone,  and  is  usually  rather  more  than  four  inches.  The 
small  diameter  of  the  lower  strait,  is  from  the  tuber  of  one  ischium, 
to  that  of  the  other;  and  is  about  four  inches.  From  this  it 
will  be  seen,  that  the  great  diameter  of  the  lower  strait,  traverses 
the  great  diameter  of  the  superior  strait  at  right  angles — this 
should  be  constantly  borne  in  mind. 

47.  It  must  also  be  mentioned,  that  not  only  the  diameters  of 
the  superior  and  inferior  straits  do  not  coincide,  but,  that  their 
axes  are  also  very  different,  owing  principally  to  the  curvature 
of  the  lumbar  vertebrae,  the  promontory  of  the  sacrum,  and  the 
retiring  of  this  bone  very  considerably  backwards. 

48.  The  deviations  from  the  standard  measurement,  are  so 
numerous,  that  it  would  be  almost  impossible  to  enumerate  them, 
were  it  even  useful;  I  shall  not  therefore  descend  to  such  detail, 
as  it  would  fatigue  the  memory,  without  benefiting  the  under- 
standing.    I  shall  content  myself  with  pointing  out  only  such 


OF  DEFORMITY  OP  THE  PELVIS.  29 

variations  as  shall  be  practically  useful;  or  such  as  would  require 
a  difference  in  the  mode  of  terminating  the  labour. 

49.  Deformities  of  the  pelvis  consist,  first,  in  an  access  of  size 
in  the  diameters  of  this  cavity;  and,  secondly,  in  a  defect  of 
them.  The  first  presents  scarcely  any  obstacle  that  is  not  sur- 
mountable by  common  means;  as  a  precipitation  of  the  uterus 
within  the  pelvis  during  gestation  is  the  chief  evil,  occasioning 
some  inconvenience  or  embarrassment  to  the  flow  of  urine,  the 
alvine  discharges,  and  the  locomotion  of  the  woman;  during 
parturition,  a  too  rapid  labour,  threatening  the  escape  of  the 
uterus  with  its  contents,  from  the  os  externum;  and  after  the 
birth  of  the  child,  giving  rise  to  a  profuse  and  alarming  haemor- 
rhage, by  the  uterus  being  too  suddenly  emptied,  by  the  hasty  ex- 
pulsion of  its  contents. 

50.  The  first  of  these  inconveniences  may  be  remedied  by  the 
application  of  a  proper-sized  pessary — the  second  may  be  in  a 
great  measure  prevented  by  a  judicious  management  of  the  case 
during  labour:  1.  By  forbidding  the  woman  to  bear  down  during 
pain.  2.  By  opposing  the  too  rapid  escape  of  the  child,  by  press- 
ing firmly  against  it  with  the  fingers  within  the  vagina,  so  as  in 
some  measure  to  counteract  the  influence  of  the  pains,  if  the 
uterus  be  but  in  part  dilated;  and  if  fully  dilated,  by  making  a 
firm  pressure  agaiflst  the  perinseum  with  the  extended  hand,  so 
as  to  allow  of  the  more  gradual  passage  of  the  head.  The  third, 
may  be  at  least  very  much  diminished,  by  brisk  frictions  upon 
the  abdomen,  immediately  over  the  uterus;  by  a  proper  manage- 
ment of  the  placenta;  and  by  the  immediate  exhibition  of  twenty 
grains  of  the  powdered  secale  cornutuni. 

51.  That  departure  from  the  standard  pelvis,  (4G)  which  con- 
sists in  a  diminution  of  its  principal  diameters,  is  much  more 
common,  and  much  more  serious  in  its  consequences,  than  the 
one  I  have  just  considered:  for  the  difficulties  are  increased  in 
proportion  almost  to  the  deviation  from  the  healthy  proportions 
just  enumerated. 

52.  The  most  common  cause  of  the  distortions  of  the  pelvis, 
is  rachitis  in  infancy  and  childhood;  and  of  malacosteon,  itj  the 
more  advanced  periods  of  life.  The  former  of  these  diseases 
hinders  the  proper  consolidation  of  the  bones;  and  thus  exposes 
them  to  the  influence  of  any  pressure  that  they  may  be  subject 
to,  during  its  continuance.  This  being  the  case,  it  will  be  very 
readily  understood  how  a  pelvis  shall  receive  injury  while  labour- 


30  OP  DEFORMITY  OP  THE  PELVIS. 

ing  under  this  disease;  for  on  it  is  exerted,  the  weight  of  the 
body  from  above,  when  the  child  is  either  sitting  or  standing; 
this  carries  the  projection  of  the  sacrum  still  more  forward;  while 
the  acetabula  serve  as  fulcra  to  the  lower  extremities,  when  it 
is  standing  on  its  feet,  and  thus  obliges  the  yielding  bones  to  re- 
tire towards  the  sacrum;  hence,  in  some  extreme  cases,  the  ap- 
proximation of  these  parts  is  such,  as  to  leave  but  a  very  few 
lines  of  opening  between  them. 

53.  It  rarely  happens  that  every  part  of  the  pelvis  is  equally 
affected  by  rickets;  and  when  it  is  not,  the  consequences  will  be 
different,  both  in  degree,  and  in  location.  Sometimes,  but  one 
side  will  have  suffered  by  this  extraordinary  disease;  while 
the  opposite  shall  be  free  from  all  complaint,  and  preserve  its 
original  healthy  conformation — at  others,  it  is  still  more  partial, 
and  only  affects  one  small  part  of  this  cavity — while  again,  every 
portion  of  it  seems  to  participate  in  the  derangement;  then  the 
consequences  become  most  lamentably  serious.  The  upper  strait 
is  generally  the  most  injured,  and  that  almost  constantly  in  the 
direction  of  its  antero-posterior  diameter  ;  leaving  the  transversal 
one  as  large,  and'sometimeseven  larger  than  usual;  and  the  inferior 
strait  sometimes  without  blemish. 

54.  When  the  inferior  strait  is  defective,  it  is  usually  in  the 
direction  of  its  small  diameter;  this  is  affected  by  the  approxi- 
mation of  the  tubers  of  the  ischia.  It  may  also  be  faulty  in 
several  other  ways — 1.  By  the  spine  or  spines  of  the  ilia  looking 
too  much  inward.     2.  By  the  symphysis  pubis  being  too  salient. 

3.  By  this  symphysis  being  too  long.  4.  By  the  processes  of  the 
ossa  pubis  running  down  in  too  perpendicular  a  direction.  The 
healthy  depth  and  form  of  the  pelvis  may  be  injured  in  various 
ways — 1.  By  the  sacrum  being  too  strait.  2.  By  its  having  too 
great  a  curvature.    3.  By  the  coccyx  looking  too  much  upwards. 

4.  By  this  bone  losing  its  regressive  motion,  by  being  anchylosed 
with  the  sacrum. 

55.  But  as  every  degree  of  deviation  does  not  render  labour 
impracticable  by  the  natural  agents  of  deliver)^  at  full  time,  it 
will  be  well  to  fix  the  boundary,  which  the  practitioners  of  Eu- 
rope of  the  greatest  experience  have  affixed  for  it.  It  seems  to 
be  pretty  generally  conceded,  that  a  labour  cannot  be  successfully 
terminated,  when  there  is  less  than  three  inches  in  the  antero- 
posterior diameter  of  the  superior  strait.  When  a  pelvis  has 
three  inches,  or  even  three  inches  and  a  half  in  this  diameter, 


OP  DEFORMITY  OF  THE  PELVIS.  31 

the  labour  is  rendered  for  the  most  part  tedious,  painful  and 
uncertain.*  We  hear  of  some  remarkable  cases,  however,  of 
children  being  born  alive,  when  there  have  been  but  two  inches 
and  three-quarters  from  the  pubes  to  the  sacrum;  but  these  must 
constantly  be  regarded  as  exceptions  to  the  general  rule;  and 
require,  that  it  may  take  place,  an  unusual  suppleness  in  the 
bones  of  the  cranium. t     See  Baudelocque,  &c. 

56.  I  have  appealed  above  to  the  experience  of  the  European 
accoucheurs  for  the  datum,  that  labour  at  full  time  is  imprac- 
ticable, when  there  is  less  than  three  inches  in  the  small  diameter 
of  the  superior  strait — I  do  this,  because  I  believe,  that  the 
united  experience  of  all  the  American  practitioners,  would  not 
have  led  to  a  correct  conclusion  on  the  subject;  as  the  occur- 
rence of  deformity  of  pelvis  in  this  country  is  so  very  rare,  as 
never  to  have  been  even  encountered  by  some  practitioners  of 
pretty  extensive  experience.  And  as  far  as  regards  my  own,  I 
must  declare,  that  I  have  not  met  with  extreme  deformity  in 
American  women,  three  times  in  my  life;  and  when  it  has 
occurred  to  such  an  extent,  as  to  render  labour  impracticable 
by  the  natural  powers,  it  has  uniformly  been  with  European 
women. J 

57.  Rickets,  among  the  children  in  this  country,  is  so  rare, 
that  practitioners  of  considerable  practice  have  declared  to  me, 
they  have  not  witnessed  a  case, — nor  is  this  to  be  much  won- 
dered at;  since  the  remote  causes  of  this  disease  are  rarely 
present.  Our  population,  even  in  our  largest  cities,  is  not 
crowded  like  those  in  many  parts  of  Europe.  That  we  have 
many  poor,  must  be  confessed;  but  even  that  poor  enjoy  com- 
paratively, a  purity  of  air,  and  a  wholesomeness  of  diet,  unknown 
to  many  of  the  same  class  in  Great  Britain,  or  in  many  parts  of 
the  continent  of  Europe.  Very  little,  indeed,  of  our  population, 
live  under  ground,  or  very  thickly  crowded  together.  They  are 
not  impacted  in  confined  manufactories,  nor  exposed  to  many 

*  This  can  be  easily  understood,  when  it  is  recollected,  that  the  ti-ansversal 
diameter  of  the  child's  head  (82)  very  rarely  can  be  reduced  to  less  than  three 
inches,  with  impunity;  consequently  when  this  diameter  measures  more  than 
three  inches,  or  the  antero-posterior  diameter  of  the  pelvis  measm-es  ratlier  less, 
the  labour  must  always  be  protracted,  and  dang'erous  to  the  child. 

t  The  French  measure  is  rather  more  than  the  Eng-hsh;  that  is,  the  French 
inch  is  thu-teen  lines  English.  A  line  is  the  twelfth  of  an  inch  ;  consequently 
two  inches  three-quarters  French,  make  three  inches  within  a  fraction,  English. 

+  In  this  I  am  happy  to  find  myself  supported  by  the  testimony  of  Professor 
James,  in  a  note  affixed  to  his  edition  of  Burns'  Midwifery.    Note  k.  p.  35. 


32  OF  DEFORMITY  OF  THE  PELVIS. 

of  their  deleterious  operations.  It  is  a  rare  occurrence,  if  even 
our  beggars  do  not  I'egale  themselves  daily,  on  more  or  less  of 
animal  food;  and  certainly  the  population  with  us,  which  would 
correspond  with  the  common  manufacturers  of  Europe,  are  for 
the  most  part,  sufficiently,  nay,  oftentimes,  abundantly  supplied 
with  it;  hence,  our  general  exemption  from  rickets,  and  of  course 
our  freedom  from  its  consequences. 

58.  I  have  said  above,  (53),  that  when  a  pelvis  is  injured  in 
its  proper  proportions,  it  is  almost  always  in  the  small  diameter 
of  the  superior  strait.  Dr.  Denman,  however,  declares  it  to  be 
always  in  this  diameter,  when  this  strait  is  faulty,  and  never  in 
the  direction  of  the  great  one;  but  in  this  I  must  differ  from  this 
experienced  and  respectable  practitioner;  for  it  was  my  chance 
to  meet  with  two  instances  of  this  kind  in  practice,  as  well  as  to 
be  in  possession  of  a  natural  pelvis,  where  the  diameters  at  the 
upper  strait  are  reversed.  Besides,  Baudelocque  admits  the 
fact,  though  he  says  it  is  very  rare. 

59.  One  of  the  cases  alluded  to  above,  occurred  to  me  within 
a  few  years,  and,  as  it  is  one  of  some  interest  from  its  rarity,  I 
will  relate  it.     On  the  18th  March,  182-4,  at  9  o'clock,  A.  M.  I 

was  called  to  Mrs.  ,  in  labour  with  her  seventh  child.     She 

had  been  complaining  during  the  whole  of  the  previous  night, 
but  the  pains  did  not  become  efficient  in  her  estimation,  until 
about  the  time  I  was  sent  for — at  this  time  the  pains  were  very 
slow,  but  pretty  forcing.  Upon  examining  per  vaginam,  the  os 
uteri  was  found  but  little  dilated,  much  tumefied,  but  not  rigid. 
As  there  was  no  immediate  necessity  for  my  presence,  1  took 
my  leave,  desiring  the  nurse  to  send  immediately,  should  any 
change  take  place  before  my  intended  return.  1  saw  her  several 
times  during  the  day,  although  no  alteration  had  taken  place, 
in  either  the  force  or  frequency  of  her  pains.  At  about  10 
o'clock,  P.  M.  of  the  same  day,  I  was  again  summoned,  in  con- 
sequence, as  the  nurse  said,  of  her  having  had  several  pains  nearer 
each  other  and  ^^ smarter.''''  Upon  a  second  examination  every- 
thing was  found  pretty  much  as  it  was  in  the  morning — in  the 
course  of  two  hours  more  the  pains  became  more  frequent  and 
urgent;  and  the  os  uteri  was  found  more  dilated,  but  still  tumid; 
the  head  of  the  child  still  very  high  up,  indeed,  was  scarcely  to  be 
felt.  Two  hours  more  were  unprofitably  employed,  in  the  hope 
of  the  advancement  of  the  head;  thinking  it  probable  that  this. 
did  not  take  place,  because  the  membranes  were  entire,  and  ap- 
parently  more  than  usually  rigid,  I   ruptured   them  and  gave 


OP  DEFORMITY  OF  THE  PELVIS.  33 

issue  to  a  very  moderate  quantity  of  liquor  amnii — the  head  did 
not  yet  descend,  as  was  hoped,  though  more  within  reach;  and 
as  the  pains  were  now  rather  brisker,  without  manifestly  advan- 
cing it,  I  was  induced  to  examine  into  the  cause  of  the  delay 
more  particularly.  Upon  a  careful  search  being  made  as  regarded 
the  pelvis,  it  was  found  that  the  point  of  the  cocc)'x  looked  very 
much  up  into  the  pelvis;  and  the  projection  of  the  sacrum  could 
not  be  felt  by  the  finger;  it  seemed  to  retire  unusually  far  poste- 
riorly; the  sides  of  the  pelvis  could  be  easily  traced  at  the  upper 
strait;  and  on  the  anterior  portion  of  the  pelvis,  immediately 
behind  the  symphysis  of  the  pubes,  two  fingers  could  be  intro- 
duced with  their  breadth  between  it  and  the  child's  head.  The 
head  of  the  child  was  found  to  occupy  completely  the  transversal 
diameter  of  the  superior  strait — it  now  occurred  to  me,  that  this 
was  an  instance  of  deformity,  in  which  the  transverse  diameter 
was  injured,  and  which  of  course  produced  an  increase  in  the 
antero-posterior  diameter ;  and  that  the  head  being  placed  trans- 
versely above,  could  not  enter  the  strait  in  that  direction.  With 
this  in  view,  I  introduced  my  hand,  and  placed  the  head  in  such 
a  manner  as  to  make  the  posterior  fontanelle  answer  to  the 
pubes,  and  the  anterior  to  the  sacrum,  and  then  withdrew  it. 
Twenty  grains  of  the  ergot  were  now  given,  with  a  hope  that  the 
pains  would  follow  each  other  more  quickly,  as  well  as  be  ren- 
dered more  powerful — but  the  first  pain  after  this,  made  the  head 
descend  to  the  lower  strait,  and  four  more  delivered  it — there 
was  a  little  delay  with  the  shoulders,  but  they  followed  the 
second  or  third  pain. 

60.  This  lady,  though  tlie  mother  of  six  children  previously, 
never  had  had  an  untoward  accident  from  this  peculiar  conform- 
ation— but  her  labours  she  represented  as  having  alwa3-s  been 
very  tedious  and  severe — four  hours  of  extremely  hard  pains  was 
the  shortest  period  she  had  ever  known,  after  she  found  herself 
what  she  called  "  to  be  in  earnest." 

61.  During  the  existence  of  rickets,  the  child  is  constantly 
exposed  to  doing  itself  mischief  by  almost  any  position  it  may 
take;  if  it  be  placed  on  its  feet,  two  powers  are  acting  to  this 
end;  the  weight  of  the  body  upon  the  sacrum  from  abov^e,  and 
the  pressure  of  the  heads  of  the  thigh  bones  upon  the  acetabula 
from  below;  producing  either  moderate  or  extreme  deformity, 
as  the  disease  may  be  more  or  less  severe,  or  as  the  patient  may 
be  more  or  less  disposed  to  exert  its  lower  limbs.     In  sitting,  the 

5 


34  OF  DEFORMITY  OP  THE  PELVIS. 

weight  of  the  body  is  sustained  by  the  tubers  of  the  ischia,  and 
the  point  of  the  sacrum ;  hence  the  latter  may  become  too  much 
curved,  and  the  former  be  made  to  injure  the  length  of  the  pro- 
cesses of  these  bones,  as  well  as  those  of  the  pubes,  and  thus  do 
mischief  to  the  arch  formed  by  these  bones.  If  carried  in  the 
arms  too  constantly,  the  whole  of  the  lateral  portions  of  the  pelvis 
may  become  injured  by  the  pressure  of  the  nurse's  arms. 

62.  To  guard  against  these  evils,  Baudelocque*  suggests  a  very 
important  practical  direction;  which  is,  to  keep  the  patient  as 
much  as  possible  in  a  horizontal  posture,  and  to  permit  him  to 
exercise  his  little  limbs  freely  by  sprawling  upon  a  bed  or  mat- 
trass. 

63.  Injuries  arising  from  malacosteon  are  more  rare,  but  not 
less  grievous  than  those  from  rickets — of  the  former  1  have 
never  witnessed  an  instance.  Mr.  Burnst  says  the  women  of 
manufacturing  towns  are  particularly  obnoxious  to  it.  It  begins 
very  soon  after  delivery,  and  very  frequently  during  pregnancy- 
and  is  comparatively  rare  in  women  who  do  not  bear  children, 
and  is  always  hurried  in  its  progress  by  gestation.  Hitherto,  no 
remedy  has  been  discovered  capable  of  arresting  its  progress,  or 
preventing  its  occurrence.  He  recommends  to  such  women  as 
are  afflicted  with  it,  to  live  "  absque  marlto." 

64.  The  pelvis  may  also  be  injured  by  exostoses  and  tumours, 
which  may  give  rise  to  either  very  difficult,  or  even  impracticable 
labour — of  the  former  I  have  witnessed  but  one  case,  and  that 
occasioned  a  rupture  of  the  uterus ;t  of  the  latter  I  have  never 
had  the  misfortune  to  meet  with  a  single  instance.  They  are 
occasioned  in  some  instances  by  enlargements  of  the  ovaria  or 
glands;  or  they  may  consist  of  some  adventitious  substance  within 
the  pelvic  cavity.  They  are  said  to  be  often  movable  when  of 
the  ovarian  kind;  and  fixed  generally  when  of  the  other.  They 
are  found  to  have  but  cellular  attachments;  and  are  of  easy  re- 
moval, by  making  an  incision  through  the  vagina,  and  evacuat- 
ing the  contents  of  the  tumour.  There  is  a  kind,  however,  which 
either  adheres  by  a  pedicle,  or  has  a  broad  base;  these  can  only 
be  rem.oved  by  deep  cutting,  and  are,  for  the  most  part,  cartila- 
ginous. 

65.  Mr.  Burns  has  laid  down  the  following  practical  rules  for 

*  System,  page  61,  par.  92. 

f  Principles  of  Midwifery.     James'  edition,  p.  34. 

:}:  See  Essays  on  Subjects  connected  witlv  Midwifery,  by  the  Author,  p.  75. 


OF  DEFORMITY  OF  THE  PELVIS.  35 

the  government  of  those,  whose  ill  luck  may  put  them  in  pos- 
session of  such  cases — 1st.  "Whenever  the  tumour  is  movable, 
it  should  be  pushed  above  the  brim  of  the  pelvis  at  the  com- 
mencement of  labour,  and  prevented  from  again  descending  be- 
fore the  child." 

66.  2d.  "  That  we  should  never  permit  the  lal)0ur  to  be  long 
protracted,  but  early  resort  to  the  means  of  relief." 

67.  3d.  "  As  it  is  impossible  to  decide  with  certainty  on  the 
nature  of  the  contents  of  many  of  these  tumours,  we  should  in 
all  cases,  where  we  cannot  push  them  up,  try  the  effects  of  punc- 
turing with  a  trocar.  If  the  contents  be  fluid,  we  evacuate  them 
more  or  less  completely ;  if  solid,  we  find  the  canula,  when  with- 
drawn, empty,  or  filled  with  clotted  blood;  if  fatty,  or  cheesy, 
the  end  of  the  tube  retains  a  portion,  and  we  are  thus  informed 
of  its  nature." 

GS.  4th.  "  When  the  size  of  the  tumour  cannot  be  sufficiently 
or  considerably  diminished  by  tapping,  I  am  inclined,  from  the 
unfavourable  result  of  cases  where  the  perforator  has  been  used, 
and  from  the  severe  and  long-continued  efforts  which  have  been 
required  to  accomplish  delivery,  to  recommend  the  extirpation 
of  the  tumour,  rather  than  the  use  of  the  crotchet.  There  may, 
however,  be  situations  where  the  incision  ought  to  be  made  in 
the  vagina;  but  these  are  rare.  But  extirpation  cannot  in  any 
mode  be  proposed,  if  firm  cohesions  have  been  contracted  be- 
tween the  tumours  and  vagina  or  rectum." 

69.  5th.  "If  the  extensive  connexions,  extent,  or  nature  of 
the  tumour,  or  danger  from  heemorrhage,  prohibit  extirpation, 
or  the  patient  will  not  submit  to  it,  and  it  has  been  early  ascer- 
tained that  tapping  is  ineffectual,  I  deem  it  an  imperative  duty  to 
urge  the  perforation  of  the  head,  or  extraction  of  the  child,  as 
soon  as  the  circumstances  of  the  case  will  permit." 

70.  6th.  "  Much  and  justly  as  the  Caesarean  operation  is  dreaded, 
it  may  with  great  propriety  be  made  a  question,  whether  in 
extreme  cases,  that  would  not  be  less  painful,  and  less  hazardous 
to  the  mother,  than  those  truly  appalling  sufferings  which  are 
sometimes  inflicted  by  the  practitioner  for  a  great  length  of  time, 
when  the  crotchet  is  employed;  whilst  it  would  save  the  child, 
if  alive  at  the  time  of  interference.  I  am  aware  that  it  may  be 
objected  to  this  opinion,  that  in  those  cases,  the  tumour  being 
softer  than  bone,  the  same  injury  will  not  be  sustained,  as  if  the 
soft  parts  had  been  pressed  with  equal  force,  and  for  the  same 


36  OF  DEFORMITY  OP  THE  PELVIS. 

time,  against  the  bones  of  a  contracted  pelvis,  and  that,  in  point 
of  fact,  recovery  has  taken  place,  though  the  strength  of  two 
able  practitioners  were  exerted  and  exhausted  during  several 
hours;  but  such  an  instance  cannot  establish  the  general  safety  of 
the  practice." 

71.  7th.  "  It  is  scarcely  necessary  for  me  to  add,  that  there 
may  be  different  degrees  of  encroachment,  which  admit  of  the 
safe  and  successful  application  of  the  forceps,  and  of  this  matter 
we  judge  by  the  size  of  the  tumour,  and  the  capacity  of  the 
pelvis."* 

72.  This  subject  is  highly  interesting  to  the  accoucheur;  and  I 
would  refer,  for  farther  information,  to  the  chapter  from,  which 
the  above  is  derived;  and  where  a  number  of  important  refer- 
ences are  made,  to  various  authorities  for  cases,  illustrative  of 
the  views  of  the  gentlemen  into  whose  hands  they  fell.  It  is  a 
matter  of  much  moment,  in  the  event  of  meeting  with  such  a 
case,  that  we  should  be  well  acquainted  with  the  best  mode  of 
treating  it;  for  however  rare  such  instances  may  be  in  this  coun- 
try, they  certainly  may  occur;  and  to  be  ignorant  of  the  resources 
of  the  art  upon  such  an  occasion,  would  be  a  reprehensible  want 
of  information.  In  addition  to  the  case  related  by  Mr,  Burns, 
we  subjoin  the  following  highly  interesting  as  well  as  important 
operation,  from  Med.  and  Phys.  Jour.  Vol,  13th,  p.  178, 

73.  "  An  account  of  two  cases  of  tumours  in  the  pelvis,  grow- 
ing out  of  the  sacro-sciatic  ligament,  one  of  which  terminated 
fatally,  and  the  other  was  cured  by  extracting  the  tumour  through 
an  incision  made  into  the  cavity  of  the  pelvis,  through  the  peri- 
tonaeum, by  P,  P,  Drew,  M.  D.  Fermoy,  county  of  Cork. 

74.  '<This  is  a  very  important  paper,  insomuch  as  it  authorizes 
an  operation,  which,  but  for  the  event,  some  people  might  have 
called  rash.  In  the  first  case,  the  boldness  of  the  undertaking 
deterred  the  surgeons  from  attempting  it,  apprehending  that  the 
tumour  might  be  connected  with  the  larger  blood-vessels  in  the 
inside  of  the  pelvis.  The  increase  of  the  tumour  at  last  produced 
a  total  interruption  to  the  passages  of  the  urethra  and  rectum;  and 
during  the  absence  of  Dr.  Drew,  the  patient  died  convulsed. 

75.  "  On  making  a  free  opening  into  the  pelvis  after  death,  the 
tumour  was  easily  turned  out,  having  no  communicating  blood- 
vessels, and  only  a  slight  attachment  to  the  surrounding  parts, 

*  See  Davis's  Elements  of  Operative  Midwifery,  page  99,  in  wliich  this  sub- 
ject is  treated  at  some  length,  and  some  interesting  views,  and  cases,  are  fur- 
nished. 


THE  EXAMINATION  OF  THE  PELVIS.  37 

excepting  at  its  neck,  which  seemed  to  grow  out  of  thesacro-sci- 
atic  ligament.  Its  texture  was  gristly,  and  the  body  of  the  tumour 
was  a  fat  gristly  substance.  This  view  of  the  parts  after  death, 
suggested  to  the  operator  a  question,  whether  the  tumour  might 
not  with  safety  have  been  removed  during  life,  by  making  an 
incision  on  one  side  of  the  perinajum  and  anus,  backwards  to- 
wards the  OS  coccygis  ? 

76.  "  About  six  months  afterwards,  the  second  case  occurred. 
The  first  time  Mr.  Drew  saw  the  woman  was  the  second  day  of 
her  labour,  in  consultation  with  three  other  medical  gentlemen, 
whose  signatures  he  has  thought  it  right  to  affix.  The  recollec- 
tion of  the  former  case,  suggested  the  only  remedy  in  the  present. 
Either  the  Csesarean  operation,  or  the  extraction  of  the  tumour, 
was  absolutely  necessary.  Besides  the  well  known  danger  of  the 
former,  even  should  it  succeed,  the  diseased  part  would  remain. 
Mr.  Drew,  therefore,  undertook  the  operation  of  extracting  the 
tumour  by  the  perinaium,  and  succeeded.  The  woman  was  soon 
after  delivered  of  a  living  child,  and,  when  the  case  was  trans- 
mitted, both  were  doing  well. 

77.  "On  the  success  of  this  important  operation,  which  does 
so  much  honour  to  the  operator  and  to  surgery,  it  is  unnecessary 
to  make  any  remarks;  but  we  cannot  dismiss  the  article  without 
wishing  gentlemen,  who  are  most  in  the  habit  of  deciding  upon 
such  cases,  to  consider  whether  some  of  those  tumours,  which 
arise  from  the  ovaria,  and  are  confined  to  the  pelvis,  might  not 
with  safety  be  extracted  in  this  manner.  We  mean  not  to  propose 
a  hazardous  operation,  where  the  patient  feels  no  other  incon- 
venience than  her  increased  bulk;  but  where  the  offices  of  the 
neighbouring  parts  are  so  much  interrupted  as  to  render  life  no 
longer  desirable,  such  a  proposal  might  be  submitted  to  the 
patient." 

Sect.  VII. —  The  Examination  of  the  Pelvis. 

78.  A  variety  of  means  have  been  proposed  for  measuring  the 
pelvis,  in  order  to  ascertain  the  diameters  of  the  various  parts, 
concerned  in  the  passage  of  the  child:  much  ingenuity  has  been 
expended  with  a  view  to,  and  hope  of  accuracy;  but  we  have 
reason  to  fear  that  none  hitherto  projected  has  attained  this  end. 
The  pelvimeter  of  Monsieur  Coutouly*  is  liable  to  serious  objec- 

*  Madame  Boivin  has  also  invented  an  instrument  which  she  calls  "intropd- 
vinietere."     Its  principles  are  much  the  same  as  Coutoidy's,  though  it  differs 


38  THE  EXAMINATION  OP  THE  PELVIS. 

tions;  especially,  as  it  afiects  to  ascertain  the  state  of  the  pelvis 
by  developing  itself  within  its  cavity;  for  1st.  It  is  very  difficult, 
as  well  as  uncertain,  in  its  application;  2d.  It  cannot  be  applied 
but  to  the  upper  strait,  not  being  calculated  for  the  measurement 
of  the  inferior  strait;  3d.  Its  results  are  not  by  any  means  certain; 
as  they  have  been  known  to  vary  several  lines  from  the  true 
measurement;  4th.  It  always  excites  pain,  however  skilfuly  ap- 
plied, and  excites  action  in  the  parts,  so  as  to  render  the  result 
very  doubtful;  5th.  It  cannot  be  applied  to  young  girls,  to  whom 
the  knowledge  of  the  state  of  their  pelves  may  be  highly  impor- 
tant. We  must  not,  therefore,  permit  ourselves  to  be  seduced  by 
its  ingenuity  and  its  apparent  simplicity. 

79.  Baudelocque  relies  with  much  confidence  upon  the  caliper; 
and  declares,  that  its  results  are  so  uniform,  as  scarcely  to  present 
a  line  of  diHerence  when  taken  before  the  body  is  opened,  and 
what  is  found  after  it  has  been  subjected  to  the  knife.  I  may 
add,  my  own  few  experiments  upon  the  dried  pelvis  are  in  entire 
conformity  with  the  assertions  of  this  most  valuable  author.  The 
mode  of  applying  it  is  extremely  simple:  one  of  the  lenticular 
extremities  of  the  calipers  is  applied  to  the  centre  of  the  mons 
veneris,  the  other  to  the  centre  of  the  depression  of  the  base  of 
the  sacrum,  or  a  little  under  the  spine  of  the  last  lumbar  verte- 
bra :  having  ascertained  exactly  the  distance  between  these  ex- 
tremities, which  is  accurately  done  by  means  of  the  graduated 
scale  attached  to  the  instrument,  you  deduct  from  it  three  inches 
for  the  base  of  the  sacrum,  and  the  anterior  extremities  of  the  ossa 
pubis,  if  the  woman  be  thin;  and  a  little  more  should  the  woman 
be  fat.  If  this  result  be  so  uniformly  accurate  as  Baudelocque 
declares,  we  need  not  want  a  more  exact  mode  of  ascertaining 
the  opening  of  the  upper  strait.  One  fear,  however,  presents  itself 
to  us,  that  considerable  error  may  be  committed,  if  the  extremities 
of  the  instrument  be  not  accurately  placed  upon  the  points  indi- 
cated; for  I  found  upon  the  prepared  pelvis,  that  a  half  inch 
higher  or  lower  than  the  spine  of  the  last  lumbar  vertebra,  would 
affect  the  result ;  now,  on  the  living  subject,  especially,  if  that 
subject  be  fat,  it  is  not  very  easy  to  determine  the  precise  spot. 
Again,  I  have  seen  dried  pelves,  so  peculiarly  distorted,  as  to  have 
the  superior  portions  of  the  ossa  pubes  pressed  almost  close  to- 

considcrably  from  it.  It  consists  of  two  branches,  which  are  introduced  sepa- 
rately— one  into  the  rectum,  and  tlie  other  into  the  vagina ;  and,  it  is  said,  may 
be  employed  in  the  virgin  as  well  as  m  the  pregnant  woman.  I  have  never  met 
with  a  particular  description  of  it. 


THE  EXAMINATION  OF  THE  PELVIS.  39 

gether;  by  which  means,  the  symphysis  pubis  is  thrown  as  much 
in  advance,  as  these  bones  lost  in  their  circular  direction.  In 
such  cases  the  whole  of  the  anterior  superior  portion  of  the  pelvis, 
not  concerned  in  the  extension  of  the  symphysis  pubis,  is  made 
almost  to  touch  the  posterior  internal  portion  of  the  pelvis;  con- 
sequently, the  distance  between  the  symphysis  pubis,  and  the 
projection  of  the  sacrum  is  greater  than  natural ;  while  the  supe- 
rior opening  of  the  pelvis,  may  not  exceed  half  an  inch;  yet 
measuring  by  the  calipers,  it  would  give  several  inches  in  the 
antero-posterior  diameter. 

SO.  We  may  also,  with  considerable  accuracy,  determine  the 
antero-posterior  diameter,  by  introducing  the  finger  into  the  va- 
gina, and  placing  its  extremity  against  the  most  projecting  part  of 
the  base  of  the  sacrum,  and  allowing  the-radial  edge  of  it  to  press 
against  the  arch  of  the  pubes;  marking  the  part  of  the  finger 
which  is  immediately  below  the  symphysis,  by  the  nail  of  the  fin- 
ger of  the  other  hand ;  ascertain  the  distance  between  it,  and  its 
extremity,  and  it  will  pretty  faithfully  give  the  width  of  the  small 
diameter  of  the  upper  strait ;  it  must,  however,  be  recollected, 
that  a  little  allowance  must  be  made  for  the  oblique  manner  in 
which  the  finger  descends  from  the  sacrum  to  the  symphysis  of 
the  pubes.  Or  we  may  ascertain  with  great  accuracy  in  time  of 
lahour,  the  degree  of  opening  at  the  superior  strait,  by  introduc- 
ing the  hand  into  the  vagina,  and  placing  some  fingers  edgewise 
between  the  posterior  part  of  the  symphj'sis  pubis,  and  the  pro- 
jection of  the  sacrum — the  width  of  the  fingers  so  employed,  can 
easily  be  measured  after  the  hand  is  withdrawn  from  the  vagina. 
Velpcau*  declares,  that  with  the  finger  we  may  estimate  every 
species  of  deformity  of  the  pelvis,  wherever  it  may  be  situated, 
or  of  whatever  nature  it  may  be. 

81.  We  may  very  nearly  assure  ourselves  of  the  extent  of  the 
small  diameter  of  the  inferior  strait,  by  placing  the  woman  in 
such  a  situation  as  will  give  extreme  flexion  to  the  thighs;  that 
is,  make  her  squat:  the  tubers  of  the  ischia  can  very  readily  be 
felt,  if  the  woman  be  not  very  fat ;  ascertain  the  space  between 
the  finger  placed  on  each  tuber,  and  it  will  give  you  the  width  of 
the  lower  strait  pretty  accurately,  especially  if  you  deduct  two 
or  three  lines  for  the  thickness  of  the  bones. 

*  De  I'Art  des  Accouchemens,  Tom.  I.  p.  51. 


40 


CHAPTER  II. 


OF  THE  CHILD  S  HEAD. 


82.  It  is  absolutely  necessary  for  the  well  understanding  of  the 
mechanism  of  labour,  that  the  various  dimensions  of  the  child's 
head  be  accurately  known,  as  a  proper  relation  must  exist  be- 
tween it  and  the  cavity  through  which  it  is  .to  pass,  that  labour 
may  not  be  obstructed.  We  are  to  consider  four  principal  diame- 
ters, as  belonging  to  the  head,  viz.  1st,  The  oblique:  this  diameter 
runs  from  the  symphysis  of  the  chin  to  the  posterior  and  superior 
extremities  of  the  parietal  bones,  or  posterior  extremity  of  the 
sagital  suture;  2.  The  longitudinal  diameter:  this  runs  from  the 
centre  of  the  forehead  to  the  top  of  the  lamboidal  suture;  3d.  The 
perpendicular,  or  the  diameter  subtending  from  the  summit  of  the 
head,  to  the  base  of  the  cranium;  4th.  The  transversal,  or  the 
diameter  which  extends  from  one  parietal  protuberance  to  the 
other. 

S3.  The  first  of  these  diameters  will  be  constantly  called  the 
large  diameter  of  the  child's  head;  the  second  will  be  called  the 
longitudinal  diameter;  and  the  third  the  perpendicular  diameter; 
while  the  fourth  will  constantly  be  considered  as  the  small  dia- 
meter. 

84.  These  diameters  are  very  often  altered  from  their  natural 
measurement  during  the  progress  of  labour,  by  tlie  pressure  the 
head  sustains  in  its  passage  through  the  pelvis;  but  all  cannot  be 
diminished  or  increased  at  the  same  time.  If  the  head  be  so 
strongly  pressed  as  to  diminish  one  diameter,  it  is  sure  to  be  in- 
creased in  another;  for  instance,  if  the  transverse  diameter  be 
diminished,  the  oblique  will  as  certainly  be  augmented;  and 
when  the  head  becomes  much  elongated,  as  it  sometimes  does, 
it  is  almost  always  in  the  direction  of  this  last  diameter. 

85.  The  extent  to  which  this  elongation  in  one  direction,  and 
diminution  in  another,  can  be  carried,  must  vary  considerably  in 
individual  cases;  owing  to  the  degree  of  pliability  of  the  bones; 
the  extent  of  separation  of  the  sutures,  and  the  size  of  the  fon- 
tanelles;  the  transverse  diameter  may  be  diminished,  sometimes 
six  or  eight  lines,  while  the  same  length  may  be  gained  by  the 
oblique.     This  compression,  however,  must  necessarily  have  its 


OF  THE  child's  HEAD.  41 

limit;  and  this  should  constantly  be  borne  in  mind ;  especially  in 
the  application  of  the  forceps.  For,  if  carried  too  far,  there  is  a 
risk  of  fracturing  the  bones,  wounding,  or  too  strongly  pressing 
the  brain,  or  producing  extravasation  within  its  substance,  or  in  the 
cavity  of  the  cranium.  Owing  to  the  different  degrees  of  hard- 
ness to  which  the  bones  of  the  foetal  head  may  arrive  while  in 
utero,  there  must  necessarily  be  a  difference  in  the  risk  the  child 
runs  from  compression ;  one  head  suffering  with  impunity  a  loss  of 
six  or  eight  lines  in  one  of  its  diameters,  while  half  this  might  be 
fatal  to  another.  The  perpendicular  diameter  suffers  in  general  but 
little  by  the  efforts  of  labour,  however  long-continued;  or  how- 
ever strongly  the  head  ma}^  be  urged.  The  longitudinal  diame- 
ter, when  the  head  is  well  situated^  is  but  little  liable  to  com- 
pression, or  alteration ;  but  when  it  does,  it  increases  the  head 
in  the  direction  of  the  transverse  diameter. 

86.  The  child's  head,  like  that  of  the  adult,  is  composed  of 
a  number  of  bony  pieces;  but  they  are  not  united  in  the 
same  manner:  in  the  child's  head  the  principal  bones,  (and  these 
as  regards  our  subject,  are  all  we  have  to  consider,)  are  tied 
together  by  a  firm  ligamentous  substance;  and  the  lines  formed 
by  this  union  are  called  sutures;  these,  are  three  in  number.  1st. 
The  sagital  suture ;  or  the  line  of  union  from  the  anterior  portion 
of  the  occipital  bone  to  the  root  of  the  nose;  passing  between, 
and  connecting  the  parietalia,  and  dividing,  yet  connecting  the 
frontal  bone,  into  two  equal  portions.  2d.  The  coronal  suture  ; 
or  the  line  which  connects  the  anterior  portions  of  the  parietalia, 
and  the  posterior  and  semicircular  portions  of  the  frontal  bone  ; 
and  passes  from  near  the  superior  portion  of  one  ear  to  that  of 
the  other.  3d.  The  lamboidal  suture ;  or  the  line  serving  to  tie 
together  the  posterior  portions  of  the  parietalia,  and  the  anterior 
superior  portion  of  the  occipital  bone. 

87.  From  this  arrangement,  it  will  be  seen,  that  the  sagital 
suture  traverses  the  coronal  suture  at  nearly  right  angles;  and 
at  the  points  of  decussation  leaves  an  open  space*  or  fontanelle. 
This  is  not  always  of  the  same  size,  owing  to  the  more  or  less 
perfect  ossification  of  the  bones — but  we  always  remark  in  it 
the  following  circumstances,  and  which  deserve  to  be  noticed,  as 
they  serve  to  distinguish  it  from  the  one  next  to  "be  mentioned-— 

*  I  have  met  with  two  instances  in  cliildi-en  of  the  same  individual,  of  an  in- 
termediate fontanelle — these  in  botli  cases  wei'e  situated  about  midway,  from 
the  anterior,  to  the  posterior  fontanelle. 


42  OP  THE  child's  head. 

there  are  always  four  bony  angles  at  this  fontanelle ;  the  edges  of 
which  are  almost  always  tipped  with  cartilage;  easily  depressed 
and  smooth;  and  very  often,  nay  almost  always,  a  space  of  con- 
siderable size  is  left,  which  is  soft,  smooth,  and  yielding,  and  can 
be  distinctly  felt  by  the  point  of  the  finger;  this  is  called  the 
anterior  fontanelle.  The  other  fontanelle  is  formed  by  the  ter- 
mination of  the  sagital,  in  the  centre  of  the  lamboidal  suture; 
and  has  but  three  bony  angles ;  two  by  the  posterior  and  superior 
points  of  the  parietalia,  and  the  central  point,  of  the  occipital 
bone.  The  union  of  these  last  named  sutures  does  not  leave  the 
same  degree  of  opening  as  the  one  we  have  just  considered; 
though  sometimes  it  is  considerable,  but  always  much  less  than 
the  anterior — for  when  the  posterior  is  well  marked,  the  anterior 
is  constantly  found  to  be  larger.  Besides  the  circumstance  last 
mentioned,  we  frequently  remark,  that  the  edges  of  the  bony 
angles  forming  the  posterior  fontanelle,  are  more  completely  ossi- 
fied, and  present  to  the  finger  when  pressed  a  serrated  edge;  and 
sometimes  these  little  bony  projections  are  so  strongly  marked, 
as  to  resemble  small  tooth-like  processes ;  a  character,  which  the 
edges  of  the  anterior  fontanelle  never  possess;  and  which  serves 
very  certainly  to  distinguish  it  from  the  other. 

88.  It  sometimes  happens,  however,  that  the  sagital  suture  is 
continued  through  the  middle  of  the  OS  occipitis  to  its  base;  in 
such  case,  four  bony  points  are  offered  to  the  touch;  but  their 
size  and  general  character  are  so  different  from  the  anterior,  as 
but  very  rarely  to  mislead. 

89.  We  would  earnestly  recommend  the  study  of  the  fonta- 
nelles  and  sutures,  to  the  beginner  in  the  practice  of  midwifery  ; 
he  should  very  early  accustom  himself  to  touch  and  distinguish 
them — it  will  lead  him  to  a  knowledge  of  the  situation  of  the 
head  when  within  the  pelvis ;  and  constantly,  and  certainly  ap- 
prize him  of  any  departure  from  its  best  position ;  and  thus  ena- 
ble him,  at  a  proper  time,  to  effect  any  change  that  may  be  ne- 
cessary, with  a  view  to  render  the  labour  safer,  easier,  and  of 
more  speedy  termination.  No  man  can  render  assistance  with 
any  certainty,  where  the  head  has  departed  from  its  proper  route, 
who  shall  be  incapable  of  distinguishing  this  aberration  by  the 
touch — he  will  either  not  distinguish  the  faulty  position,  and  thus 
condemn  the  poor  woman  to  protracted  and  unnecessary  suffer- 
ing; or  he  will  blindly,  and  rashly  attempt  relief,  at  the  hazard 
of  the  lives  of  mother  and  child. 


OP  THE  child's  head.  43 

90.  Many  rely  upon  the  position  of  the  ear,  for  the  knowledge 
of  the  situation  of  the  head;  but  we  seriously  object  to  this  un- 
certain test:  1st.  Because  the  head  may  be  so  high  in  the  pelvis, 
as  to  be  out  of  the  reach  of  the  finger  when  it  may  be  essential  to 
determine  its  position,  whereas  the  fontatielles  can  always  be 
commanded  ;  2d.  The  head  may  be  so  impacted  in  the  pelvis,  as 
to  prevent  the  finger  from  passing  to  the  ear;  3d.  And  when  this 
is  felt,  it  may  give,  from  some  peculiarity  of  situation,  or  the  im- 
perfection of  the  touch,  a  wrong  impression  of  its  position;  4th. 
When  the  head  is  still  enclosed  within  the  uterus,  the  finger  can- 
not always  be  made  to  pass  sufficiently  far  under  its  edge  to 
reach  the  ear,  though  the  os  uteri  may  be  sufficientl}^  dilated  for 
all  the  purposes  of  delivery. 

91.  It  is  important,  that  the  connexion  of  the  head  of  the 
child  with  the  trunk,  should  also  be  well  understood ;  otherwise 
the  child  may  sustain  much  injury,  if  not  death,  from  an  ignorance 
of  it — it  must  be  constantly  recollected,  that  the  head  cannot 
with  safety  execute  a  motion  upon  the  neck  beyond  a  quarter  of 
a  circle,  when  it  is  freed  from  the  pelvis,  and  the  body  retained 
within  that  cavity;  nor  can  the  cervical  vertebrse  more  safely 
perform  a  greater  sweep,  when  the  head  is  detained,  and  the 
body  is  without.  A  want  of  attention  to  this  fact,  I  have  great 
reason  to  fear,  has  caused  the  death  of  more  children  than  I 
would  dare  to  mention;  especially,  when  they  have  presented  by 
the  breech,  feet,  or  knees,  or  when  turning  has  been  resorted  to. 
I  well  recollect  one  instance  of  footling  presentation,  where  the 
child  was  delivered  to  the  head,  and  the  midwife  who  had  charge 
of  the  case,  could  not  succeed  in  delivering  it;  I  was  sent  for; 
and  was  obliged  to  give  two  entire  turns  of  the  body,  before  the 
twist  was  removed  from  the  neck;  I  need  not  mention  the  fate 
of  the  child.  Fewer  errors  of  this  kind  are  committed  when  the 
head  presents;  not  because  the  cases  are  not  similar,  under  equal 
circumstances;  but  because  the  shoulders  are  seldom  long  retain- 
ed after  the  exit  of  the  head ;  and  consequently,  there  is  less 
temptation  to  employ  ill-directed  force. 


44 


CHAPTER  III. 


OF  THE  GENITAL  ORGANS. 


92.  Op  the  parts  concerned  in  generation  and  delivery,  some 
are  detected  without  the  use  of  the  knife,  while  others  are  only 
brought  into  view  by  dissection;  hence,  they  have  been  divided 
into  external  and  internal.  The  external  consist  of  the  mons 
veneris,  the  labia,  the  clitoris,  the  nymphse,  the  meatus  urinarius, 
the  hymen,  the  orifice  of  the  vagina,  the  carunculre  myrtiformes, 
the  frffinum  labiorum  or  fourchette,  and  the  fossa  navicularis. 
The  internal  organs  are  the  uterus,  the  fallopian  tubes,  the  ovaria, 
the  ligaments,  and  the  vagina. 

93.  Immediately  over  the  symphysis  of  the  pubis,  and  part  of 
the  insertion  of  the  recti  muscles,  we  find  a  prominence,  which 
in  the  adult  is  covered  with  hair — this  is  the  mons  veneris;  it 
consists  of  an  accumulation  of  cellular,  and  adipose  membrane — 
we  know  of  no  decided  use  of  this  part ;  and  more  especially, 
for  its  being  covered  with  hair.  Apparently  taking  rise  from 
this  part,  we  find  two  bodies  of  similar  appearance  and  texture, 
running  parallel  to  each  other,  in  a  course  downward  and  back- 
■vvard — these  are  the  labia  pudendi ;  their  external  faces  are  co- 
vered with  the  common  skin,  and  are  studded  like  the  mons 
veneris  with  capilli ;  their  internal  surfaces  are  covered  with  a 
beautifully  fine  and  sensible  membrane,  of  a  florid  colour  in 
young  subjects;  which  is  abundantly  supplied  with  glands,  that 
constantly  secrete  a  fluid  for  the  especial  protection  of  these  parts 
against  adhesion. 

94.  On  the  separation  of  the  labia,  several  other  parts  are  im- 
mediately brought  into  view;  the  clitoris  presents  itself,  directly 
beneath  the  superior  union,  or,  if  you  please,  the  origin  of  these 
bodies.  It  consists  of  several  parts ;  as  two  cmira,  which  have 
their  origin  in  the  ossa  ischia,  and  running  along  the  branches  of 
the  ossa  pubis,  unite  upon  the  symphysis,  and  form  the  body  of 
this  organ ;  these  crura  are  connected  by  ligament  to  these  bones, 
somewhat  after  the  manner  of  the  penis  in  males;  its  external 
termination,  from  its  supposed  resemblance,  has  been  called  its 
glans;  but  it  is  without  urethra,  being  imperforate;  a  duplication 
of  the  internal  membrane  of  the  la])ia,  forms  its  preputium.     It 


OF  THE  GENITAL  ORGANS.  45 

has,  like  the  male  organ,  two  corpora  cavernosa,  and  an  interme- 
diate septum;  it  has  also  the  power  of  erection,  through  the 
agency  of  two  erector  muscles,  which  arise  from  the  ossa  ischia, 
and  are  inserted  into  the  corpora  cavernosa.  It  is  supposed,  but 
without  sufficient  proof,  to  contribute  to  sensual  gratification,* 
It  is  this  part,  when  preternaturally  enlarged,  which  has  given 
rise  to  the  various  reports  of  hermaphrodites. 

95.  It  is  furnished  with  blood-vessels  from  several  sources; 
both  arteries  and  veins  are  branches  from  the  hypogastrics  and 
vasa  pudfenda.  Its  nerves,  which  arise  from  the  sacri,  endow  it 
with  great  sensibility. 

96.  Depending  as  it  were  from  the  clitoris,  are  two  similar 
bodies  called  the  nymphai — they  separate  more  widely  as  they 
proceed,  and  run  downward  towards  the  os  externum ;  they  are 
very  vascular;  and  in  virgins  are,  like  the  whole  of  the  internal 
face  of  the  vulva,  of  a  bright  red  colour,  and  are  supposed  to 
augment  venereal  gratification — they  certainly  are  very  distensi- 
ble, and  unquestionably  contribute,  by  this  property,  to  diminish 
the  risk  of  laceration  from  the  passage  of  the  child  during  la- 
bour, t 

97.  In  the  centre  of,  and  between  the  inferior  extremities  of 
the  nymphaj,  the  orifice  of  the  urethra  is  found;  and  though, 
strictly  speaking,  it  does  not  belong  to  the  organs  of  generation, 
yet  it  is  of  such  importance  in  many  cases  connected  with  gesta- 
tion and  labour,  as  to  render  a  familiar  acquaintance  with  it  ab- 
solutely necessary  in  the  practice  of  midwifery.  I  shall  have, 
upon  another  occasion,  to  revert  to  this  part  with  more  exacti- 
tude as  regards  location,  &c.  The  canal  or  urethra,  of  which 
this  is  the  outlet,  is  from  one  inch  and  a  half,  to  two  inches  in 
length,,  and  proceeds  from  the  urinary  bladder;  it  is  more  capa- 
cious, and  more  distensible,  than  the  male  urethra;  permitting,  in 
many  instances,  calculi  of  considerable  size  to  pass  along  it  with- 
out much  inconvenience  or  distress;  and  if  this  tube  be  slit  up 

*  Velpeau  seems  to  be  of  tliis  opinion,  but  gives  no  proofs  in  support  of  it;  he 
says,  "The  intimate  structure  of  the  clitoris  is  such,  as  to  allow  of  an  accumula- 
tion of  blood  in  it  during  coition,  so  as  to  become  swollen  and  erect;  the  fine 
membrane  which  covers  it  is  very  sensible,  and  hence  has  been  looked  upon  as 
the  principal  seat  of  venereal  pleasure." —  Vdpcau,  Traiti,  Elimentaire  de  tArt 
des  Accouchmcns.  Tom.  I.  p.  60. 

t  Velpeau  denies  very  dogmatically  what  is  here  asserted  to  lie  the  supposed 
uses  of  the  nymphx,  (as  first  suggested  we  believe  by  Smellie,)  but  without 
giving  the  reasons  for  his  objections. 


46  OP  THE  GENITAL  OROANS. 

to  its  origin,  it  will  be  found  studded  with  numerous  mucous 
lacunae;  two  of  which  at  its  orifice  are  particularly  large — in  the 
unimpregnated  state  of  the  uterus,  its  direction  is  nearly  horizontal. 

98.  Below  the  orifice  of  the  urethra,  and  almost  immediately 
under  the  symphysis  pubis,  the  orifice  of  the  vagina  or  os  exter- 
num is  found — it  may  be  said  to  occupy,  in  its  undisturbed  state, 
a  considerable  portion  of  the  arch  of  the  pubes,  but  its  limits  are 
very  much  increased  during  the  passage  of  the  head  of  the  child 
at  the  end  of  labour;  it  then  extends  below  the  tubers  of  the 
ischia.  It  is  surrounded  by  a  sphincter,  which  arises  from  the 
sphincter  ani;  and  is  accompanied  by  the  plexus  retiformis. 
This  sphincter  has  various  degrees  of  power;  owing  either  to  ori- 
ginal conformation,  or  the  habit  of  exerting  it,  or  both.  A  medi- 
cal friend  informed  me,  he  had  a  patient  who  had  such  entire 
control  over  this  constrictor,  as  to  enable  her  to  retain  an  injec- 
tion per  vaginam,  as  long  as  she  pleased. 

99.  In  the  virgin  state,  this  orifice  is  almost  always  partially 
occluded  by  a  membraneous  expansion,  called  the  hymen — this 
partition  is  situated  immediately  within  the  orifice  of  the  vagina, 
and  seems  to  spread  itself  over,  and  be  the  connecting  medium, 
of  the  carunculae  myrtiformes.  It  is  almost  constantly  pierced 
by  a  hole,  which  gives  issue  to  the  menstruous  secretion;  when 
it  is  not,  it  gives  occasion  to  such  an  accumulation  of  this  fluid 
as  to  produce  great  pain,  and  to  require,  for  the  most  part,  the 
interference  of  art.  This  membrane  has  been  considered  by 
many  celebrated  anatomists,  as  a  creature  of  the  imagination ; 
but  I  am  abundantly  convinced  by  multiplied  observation,  that 
it  really  exists;  and  in  the  museum  of  our  Medical  College,  seve- 
ral beautiful  specimens  may  be  seen.  Among  the  Jews,  a  dis- 
charge of  blood,  which  was  supposed  to  proceed  from  the  rup- 
ture of  this  membrane  in  primo  coitu,  was  considered  as  the  test 
of  virginity. 

100.  The  existence  of  the  hymen,  we  have  just  said,  has  been 
doubted;  men  of  much  learning  and  talent  are  enlisted  on  both 
sides  of  the  question,  and  much  difficulty  would  be  experienced 
by  the  tyro  in  anatomy,  which  side  of  the  question  he  would 
adopt.  But  if  opportunity  present  itself  for  the  investigation 
upon  a  proper  subject,  either  the  dead  or  living,  it  will  not  fail  to 
convince  him  of  the  existence  of  this  membrane;  for  our  own 
experience  declares  it  palpable ;  and  this  sufficiently  often,  to 
unhesitatingly  assert  its  existence.     One  positive  fact,  is  worth 


OF  THE  GENITAL  ORGANS.  47 

a  dozen  negative  ones;  it  not  being  always  found,  does  not  prove 
that  it  never  exists;  and  this  is  pretty  much  the  state  of  the 
question  upon  this  point.  We  cannot  possibly  doubt  its  existence, 
because  we  have  frequently  seen  it;  and  if  it  do  not  prove  to  be 
universal,  even  where  it  might  be  reasonably  expected,  it  sliould 
be  recollected,  that  many  causes  may  operate  its  destruction; 
without  a  vicious  inclination,  or  moral  turpitude  being  of  the 
number. 

101.  Besides,  we  have  lately  seen  an  interesting  report  upon 
"  the  condition  of  the  female  genital  organs  at  birth,"  by  L. 
Senn,  of  la  Maternite  de  Paris,"  in  which  he  says,  "  in  examin- 
ing between  three  and  four  hundred  children,  from  two  to  four 
years  of  age,  I  did  not  fail  in  a  single  instance  to  find  the  hymen." 
He  adds,  ''I'hymen  ne  manque  jamais,  et  ne  varie  pas  dans 
sa  position;  mais  il  presente  des  differences  de  form,  qui  in- 
fluent specialment  la  figure  et  I'entendue  de  Pouverture  du 
vagin."* 

102.  Immediately  at  the  external  extremity  of  the  vagina,  we 
may  observe  several  small,  fleshy,  very  vascular  bodies,  which 
seem  to  serve  as  valves  to  this  orifice — these  are  the  carunculs 
myrtiformes;  and  upon  which  in  the  virgin  state,  the  hymen 
appears  to  spread  itself;  and  are  considered  even  now  by  many, 
to  be  the  fragments  of  this  membrane— but  these  bodies  exist 
independently  of  each  other;  and  are  besides  very  much  too  large 
to  be  the  debris  of  the  hymen — their  use  appears  to  be,  to  hinder 
the  urine,  and  even  other  foreign  bodies,  from  passing  into  the 
vagina;  to  contribute  to  the  venereal  orgasm;  to  provide  in 
the  last  moments  of  labour  a  supply  of  distensible  material,  and 
by  this  means  diminish  the  risk  of  severe  contusion  or  of  laceration. 

103.  In  advance  of  the  hymen,  and  a  little  below  it,  the  semi- 
lunar fold,  called  the  fourchette,  may  be  seen;  it  almost  as  cer- 
tainly belongs  to  the  virgin  as  the  hymen,  as  it  is  rarely  found 
after  delivery — between  the  hymen  and  the  fourchette,  the  fossa 
navicularis  is  situated. 

104.  The  space  directly  behind  the  inferior  terminations  of  the 
labia,  and  before  the  anus,  is  called  the  perin^eum— in  its  na- 
tural state  it  is  about  an  inch  and  a  half  in  width;  is  pretty 
dense,  though  chiefly  composed  of  cellular  membrane;  but  is 
capable  of  prodigious  extension. 

*  Joui-n.  Univ.  de  Med.  Vol.  xxvii.  272. 


48  OP  THE  INTERNAL  ORGANS. 

Sect.  I. — Of  the  Internal  Organs. 

105.  The  internal  organs  of  generation  consist  of  the  vagina, 
the  uterus  and  its  appendages,  the  fallopian  tubes,  and  the  ovaria. 
The  vagina  is  that  canal  which  leads  directly  from  the  external 
organs  to  the  uterus.  I  have  already  stated,  (99)  that  the  hymen 
in  virgins,  and  the  carunculse  myrtiformes  in  married  or  used 
women,  guard,  as  it  were,  the  entrance  of  this  canal.  Its  length 
may  be  stated  to  vary  at  different  periods  of  life;  it  is  wider  at  its 
upper  extremity  than  below;  and  more  especially,  towards  the 
sacro-iliac  symphyses,  as  its  central  portion  is  occupied  by  the 
uterus,  which  hangs  pendulous  in  it.  It  is  not  direct  in  its  course, 
dipping  fu'st  a  little  downwards,  and  then  passing  upwards  to 
meet  the  uterus,  with  which  it  is  so  united,  as  to  exhibit,  in  time 
of  labour,  no  line  or  mark  of  union,  forming  as  it  were  a  con- 
tinuous canal  with  this  organ.  It  consists  of  a  pretty  dense  cel- 
lular substance,  which  is  very  elastic,  as  is  proved  after  delivery 
by  its  quickly  restoring  itself. 

106.  It  is  lined  by  a  continuation  of  the  membrane  which 
covers  the  internal  faces  of  the  labia,  which  folds  itself  up  into 
wrinkles,  called  rugas — it  is  asserted  by  some,  that  these  rugae 
are  peculiar  to  women;  and  to  which  several  duties  are  assigned: 
1st.  That  they  contribute  to  venereal  gratification,  (but  if  this 
were  one  of  their  offices,  they  are  certainly  ill  situated.)  2d. 
That  they  serve  as  a  remora*  to  the  ejected  semen,  and  at  the 
same  time  offer  it  a  larger  surface  to  be  absorbed  from.  3.  That 
these  folds  serve  to  give  greater  length  and  breadth  to  the  vagina, 
by  stretching  out  during  labour,  and  thus  preventing  laceration. 
The  vagina  is  extremely  well  supplied  with  blood-vessels;  and, 
when  well  injected,  is  found  to  be  highly  vascular — throughout 
its  whole  surface  innumerable  glandidar  follicles  may  be  seen, 
which  constantly  secrete  a  mucous  fluid.  The  vagina  in  its 
course  forms  several  points  of  adhesion  by  means  of  cellular 
membrane:  1st.  It  adheres  very  strongly  to  the  urethra  before; 
and  2d.  Behind,  it  unites  itself  pretty  firmly  at  its  upper  part,  to 
the  rectum.  Besides,  there  are  two  small  glands,  which  Ear- 
tholine  denominated  vaginal  glands — or  the  female  prostates. 
Their  uses  are  not  accurately  determined.  Gartner  thinks  they 
may  give  rise  to,  or  have  terminating  upon  them,  the  ducts  he 
lately  discovered,  whose  purpose  is  to  convey  a  portion  of  the 
ejected  male  semen  to  the  ovaries.     They  most  probably  secrete 

*  Speculations  on  Impregnation. 


OP  THE  UTERUS  AND  ITS  DEPENDENCIES.  49 

the  milky  fluid,  discharged  by  the  female  during  venereal  grati- 
fication. 

Sect.  II. — Of  the  Uteriis  and  its  Dependencies, 
107.  The  uterus  is  situated  in  the  pelvic  cavity,  at  the  upper 
extremity  of  the  vagina;  it  is  so  placed  as  to  have  the  bladder 
before,  and  the  rectum  behind,  it ;  and  with  both  of  which,  there 
is  more  or  less  intimacy  of  connexion,  by  intervening  cellular 
membrane,  and  reflected  peritoneum.  It  is  of  a  pear-like  shape, 
but  a  little  flattened  ;  and  has  its  small  extre.mity  hanging  into  the 
vagina.  It  has  been  usual  with  writers,  for  th«  sake  of  conve- 
nience, to  divide  this  organ  into  three  parts;  namely,  fundus, 
body,  and  neck — the  fundus  is  made  to  consist  of  all  that  portion 
that  is  superior  to  the  origin  of  the  fallopian  tubes;  the  body, 
of  the  part  inferior  to  them,  and  extending  to  the  commence- 
ment of  the  neck;  and  the  neck,  of  all  that  accuminated  portion 
which  distinctly  dips  into  the  vagina,  and  terminates  in  the  os 
tincse. 

108.  The  substance  of  which  the  uterus  is  composed,  has  lono- 

been  a  matter  of  dispute  with  anatomists  and  physiologists 

some  declaring  it  to  be  muscular,  while  others  insist  it  is  in  its 
structure,  sui  generis.  Mr.  Bell*  decides  on  the  muscularity  of 
this  organ,  because  he  has  seen  and  dissected  its  fibres;  so  did 
Vesalius,  Malpighi,  Ruysch,  Hunter,t  &c.  while  Dr.  Rams- 
botham J  denies  the  fact;  and  says,  "this  notion  appears  to  be 
rather  an  assumption  derived  from  the  contractile  powers,  which 
this  viscus  is  known  to  possess,  and  which  are  supposed  only  to 
exist  on  muscularity,  than  to  originate  in  obvious  appearances. 
However  authors  may  write,  and  teachers  may  talk  about  the  uter- 
ine muscles,  no  such  structure  is  evident  to  my  senses. "     Neither 

*  Eclec.  Rep.  Vol.  V.  p.  37. 

f  Velpeau,  agreeably  to  his  own  declaration,  has-cUssected  very  many  uteri  at 
every  period  of  life  ;  he  has  examined  them  when  impregnated  and  when  unim- 
pregnated.  From  these  examinations  he  is  led  to  the  following  results :  that 
there  is  a  thin,  elastic,  cellulo-fibrous  structure  immediately  below  the  peritoneal 
covering  of  this  organ  ;  tliis  is  sometimes  but  not  always  muscular,  but  in  which 
there  is  no  determinate  arrangement  of  its  fibres.  A  thick  layer  of  fibres,  the 
direction  of  which  is  transverse.  Other  transverse  fibres,  are  found  situated 
more  deeply — but  the  longitudinal  and  oblique  fibres,  predominate,  ])articular- 
ly  at  the  neck.  And  above  is  seen  the  supposed  detrusor  placenta  of  Ruysch, 
which  appears  to  be  no  more  than  an  expansion  of  the  circular  fil)res  belonging 
to  the  fallopian  tubes.     Art  des  Accouchmens.  tom.  1.  p.  84. 

\  Practical  Obs.  Am.  ed.  p.  19. 

7 


50  OF  THE  UTERUS  AND  ITS  DEPENDENCIES. 

this  declaration  of  Dr.  R.  nor  his  reasoning  on  this  point,  has  in  the 
slightest  degree  shaken  my  faith  in  the  muscular  structure  of  this 
organ — the  whole  phenomena  of  labour  at  full  time,  and  the 
throwing  off  of  the  ovum  in  aborting,  irresistibly  force  me  to  this 
opinion.  It  is  not  at  present,  and  perhaps  it  never  may  be  de- 
cided, in  what  manner  the  fibres  of  the  uterus  dispose  of  themselves 
in  composing  this  organ;  yet  enough  of  its  structure  is  known,  I 
believe,  to  warrant  the  declaration,  that  its  functions  as  regard 
labour,  are  performed. by  the  power  of  muscular  contraction. 

I  shall  avail  myself  of  the  judicious  observations  of  Velpeau 
upon  the  subject  of  the  muscularity  of  the  uterus,  as  we  think 
they  must  carry  conviction  to  the  mind  upon  this  often  contested 
subject. 

"  Previously  to  asserting  that  the  womb  does,  or  does  not, 
contain  muscular  tissue,  it  would  have  been  proper  to  determine 
what  are  the  characters  of  that  tissue  in  general;  to  show  that 
the  red  colour  is  not  essential  to  it,  since  it  is  wanting  in  the 
muscles  of  fishes,  reptiles,  and  even  in  the  muscular  coat  of  the 
human  intestines;  and  that  the  same  is  true  of  the  fibrous  appear- 
ance, since  it  is  met  with  in  the  tendons,  aponeuroses,  &c. 
but  that  it  alone  enjoys  the  faculty  of  contractility,  and  contains 
fibrine. 

"  In  the  second  place,  it  should  be  considered  indispensable  to 
recognize  a  truth  that  is  too  much  overlooked  in  our  days;  which 
is,  that  the  fleshy  fibre  must  necessarily  pass  through  sevei'al 
less  perfect  gradations  of  developement ;  that,  in  some  organs,  it 
remains  in  the  rudimental  condition,  and  is  developed  only  by 
accident.  Thus,  the  trachea,  and  the  bronchia,  even  the  arteries 
of  large  animals,  the  elephant  among  others,  evidently  exhibit 
muscular  fibres,  while  the  same  organs  in  the  human  species 
rarely  exhibit  them  with  any  distinctness.  The  gall  bladder,  the 
vesicular  seminales,  &c.  are  not  furnished  with  them,  according 
to  most  of  the  modern  anatomists ;  but  let  these  organs  be  exa- 
mined when  their  coats,  strongly  hypertrophied,  have  been  long 
distended,  and  we  shall  be  soon  forced  to  admit  that  they  possess 
a  muscular  coat,  as  the  ancients  believed,  and  as  I  have  seen 
myself.  The  womb,  previously  to  puberty,  is  only  a  rudimental 
muscle ;  when  not  gravid,  its  organization,  it  is  true,  is  but  a 
sketch,  but  it  is  only  towards  the  end  of  pregnancy  that  we  can 
possibly  test  its  nature.  Every  circumstance  tends  to  establish 
that  the  cellulo-fibrous,  elastic  yellow  tissue  which  composes  the 
basis  of  the  inter-laminar,  and  inter-spinal  ligaments  of  the  verte- 


OF  THE  UTERUS  AND  ITS  DEPENDENCIES.  51 

brae,  constitutes  also  the  web  of  a  very  great  variety  of  other 
organs.  It  is  nowhere  more  abundant  than  in  the  uterus.  Hence 
it  appears  that  this  element  holds  a  middle  place,  and  serves  in 
some  sort  as  a  passage  between  the  cellular  and  muscular  systems; 
the  chemists  have  detected  fibrine  in  it,  and  I  have  seen  it,  on 
various  points,  transformed  into  real  contractile  tissue.  I  am 
scarcely  afraid  to  assert  that  wherever  it  is  met  with,  it  may 
accidentally  develope  muscular  fibres,  and  that  these  fibres  exist 
naturally  in  some  zoological  species. 

"  In  order,  therefore,  to  understand  the  essence  of  the  uterine 
tissue,  it  ought  to  be  studied  during  its  gravid  state;  then  only 
is  it  red,  contractile,  formed  of  tomentose  fibres;  then  only  does 
it  contain  a  large  portion  of  fibrine:  and  presents  in  a  word  all 
the  characters  of  the  most  perfect  muscular  tissue."^' 

109.  There  is  no  organ  in  the  human  body,  from  whose  struc- 
ture so  little  can  be  inferred,  as  the  unimpregnated  uterus;  in  it, 
when  laid  open  by  the  knife,  we  see  no  manifestation  of  capacity 
for  distension;  on  the  contrary,  we  observe  nothing  but  dense 
unyielding  walls,  that  would  seem  to  bid  defiance  to  any  attempt 
for  this  purpose — in  it  we  have  no  promise  of  the  immense  force 
which  it  is  destined  to  exert,  to  relieve  itself  of  the  produce  of 
conception — nor  can  we  anticipate  the  immense  distensibility  of 
its  vessels  from  pregnancy,  in  the  diminutive,  nay,  almost  im- 
perceptible ones  in  its  empty  state — so  wonderful,  and  so  varied 
are  the  changes  which  this  organ  undergoes  from  impregnation. 

110.  The  cavity  of  the  uterus  is  small  and  somewhat  of  a  tri- 
angular form;  it  terminates  below  in  the  neck,  and  its  opening  is 
termed  the  os  tineas.  The  uterus  is  lined  through  its  whole  ex- 
tent, by  a  fine  membraue,  which,  from  near  the  os  tincse  to  its 
fundus,  as  also  through  the  windings  of  the  fallopian  tubes,  is  so 
completely  identified  with  the  proper  substance  of  these  parts, 
as  to  defy  any  attempt  at  a  regular  separation — the  same  may  be 
said  of  its  peritoneal  covering;  refusing  to  dissolve  its  union  with 
the  external  portions  of  the  body  and  fundus,  by  any  attempt  that 
may  be  made  for  the  purpose,  unless  it  be  after  incipient  putre- 
faction. 

111.  It  has  uniformly  been  declared,  so  far  as  I  know,  that 
the  vvhole  of  the  internal  surface  of  the  uterus,  including  the 
neck  of  this  organ,  and  the  fallopian  tubes,  are  furnished  with 
linings,  from  a  continuation  of  the  membrane  which  gives  co- 

*  Dr.  Meigs'  ti-anslation,  p.  63. 

0 


52  OF  THE  UTERUS  AND  ITS  DEPENDENCIES. 

vering  to  the  vagina — I  have  strong  reasons  to  call  in  question, 
the  truth  of  this  arrangement;  so  far  at  least,  as  the  absence  of 
identity  of  function  would  declare  the  absence  of  identity  of 
structure — it  is  now  no  longer  a  matter  of  dispute,  that  it  is  from 
the  internal  face  of  the  uterus,  that  the  menstruous  secretion 
proceeds;  yet  this  fluid  is  neither  furnished  by  the  vagina,  nor 
by  the  fallopian  tubes;  consequently,  the  membranes  lining  these 
parts,  cannot  be  one  and  the  same.  I  assume  here  the  positive 
side  of  the  question  respecting  the  internal  face  of  the  uterus 
possessing  a  membrane,  notwithstanding  the  cavils  upon  this 
point  by  several  late  eminent  anatomists.  For  as  far  as  authority 
will  justify,  the  assumption,  it  certainly  appears  to  be  in  favour 
of  the  belief.  For,  though  Ribes,  Chaussier,  Gordon,  Madame 
Boivin,  deny  its  existence,  others  insist  upon  it.  Dr.  Francis,  of 
New  York,  assured  me  lately,  that  he  had  a  preparation  demon- 
strating its  existence;  and  Velpeau*  asserts  unequivocally  its 
presence  in  the  following  words: — 
"  112.  "II  est  vrai  que,  hors  de  temps  de  la  gestation,  on  ne 
peut  pas  toujours  demontrer  I'existence  de  la  membrane  muqueuse 
uterine;  mais  chez  plusieurs  femmes,  mortes  enceintes  ou  peu  de 
temps  apres  la  couche,  je  suis  parvenu  a  en  enlever  des  lambeaux 
tr.es-distincts.  Quand  meme  on  ne  pourrait  pas  I'isoler  mecha- 
niquement,  I'analogie  suffirait  pour  convaincre  de  sa  presence; 
les  membranes  muqueuses  sont  ejfclusivement  pourvues  de  vil- 
losites;  elles  fournissent  seules  du  mucus,  dans  I'etat  sain,  des 
mucosites  purulentes  dans  I'etat  pathologique;  c'est  a  leur  sur- 
face qu'on  voit  paraitre  les  polypes,  les  exhalations  sanguines." 
In  a  word,  we  think  the  existence  of  this  membrane  cannot  be 
denied,  as  we  have  seen  it  ourselves  after  delivery  in  several  in- 
stances; but  it  differs  from  other  mucous  membranes,  in  being 
deciduous. 

113.  The  division  of  the  uterus  into  different  portions,  was 
suggested  for  the  convenience  of  demonstration;  and  has  been 
employed  by  all  the  writers  upon  anatomy  and  midwifery,  for 
the  last  century  at  least — I  adhere  to  this  division,  but  from  very 
different  motives;  many  years  ago,  I  insisted  on  this  division  as 
essential  to  the  explanation  of  several  of  the  phenomena,  which 
this  organ  constantly  presented;  I  shall  therefore  transcribe  with- 
out apology,  my  sentiments,  as  expressed  upon  this  subject,  from 

• 
*  Art  des  Accouchmens,  Vol.  I.  p.  77. 


OF  Tllfi  UTERUS  AND  ITS  DEPENDENCIES.  53 

my  "  Essay  on  the  Means  of  lessening  Pain,  and  facilitating 
certain  cases  of  Difficult  Labour,"  p.  17.  ed.  2d. 

114.  "  I  cannot  help  regarding  the  neck  of  the  uterus  as  a  dis- 
tinct and  independent  part  from  the  body  and  fundus,  as  hav- 
ing its  own  peculiar  laws  and  actions;  and  that  this  separation  of 
powers  is  absolutely  necessary  to  the  explanation  of  some  of  the 
phenomena  exhibited  in  health  and  in  disease,  and  the  influence 
of  certain  agents  upon  this  organ. 

115.  "  My  reasons  for  thinking  so  are,  first,  that  we  find  the 
fundus  and  body  ma^  be  distended  to  a  great  extent,  without 
affecting  the  arrangement  of  the  neck;  thus,  in  every  uterine 
pregnancy,  we  see  these  parts  gradually  yield  to  the  influence  of 
the  ovum,  until  about  the  sixth  or  seventh  month ;  while  the 
neck  remains  very  much  the  same  as  before  impregnation. 

116.  "  Secondly,  that  after  the  sixth  or  seventh  month,  the 
neck  undergoes  its  changes,  while  the  fundus  and  body  remain 
in  a  great  measure  stationary;  so  that  two  distinct  processes,  or 
rather  the  same  process,  is  performed  at-  two  different  periods, 
and  in  different  parts,  in  the  order  we  have  just  mentioned. 

117.  "  Thirdly,  that  the  neck  may  be  affected  by  disease, 
while  the  fundus  and  body  may  remain  free,  and  the  reverse; 
and  that  the  neck  may  contract  and  relax,  while  the  other  parts 
are  in  opposite  'states — thus  with  women  who  are  in  the  habit  of 
aborting  from  some  peculiarity  of  the  uterus,  we  find  the  body 
and  fundus  may  be  excited  to  action,  while  the  neck  for  a  long 
time  remains  passive;  and  also  the  neck  may  relax,  and,  after 
some  time,  the  fundus  and  body  may  be  excited  to  contraction. 
And  in  cases  of  atony  of  the  uterus  after  a  too  sudden  deliver}'-, 
the  body  and  fundus  m.ay  contract,  while  the  neck  is  the  only 
part  in  fault,  and  vice  versa. 

118.  "  The  different  conditions  that  the  parts  of  the  uterus 
may  be  in  at  the  same  time,  where  atony  partially  prevails, 
would  seem  to  demonstrate  the  truth  of  wdiat  is  here  advanced. 
For  it  is  a  fact  well  known  to  almost  every  practitioner  of  mid- 
wifery, that  each  of  the  parts  into  which  we  have  divided  this 
viscus,  may  separately  and  independently  of  each  other,  be  in 
a  state  of  relaxation  or  contraction,  and  thus  exhibit  different 
phenomena,  and  be  productive  of  different  results."  From  this 
it  would  appear  that  nature  has  rcally  established  a  division  of 
the  uterus,  which  has  hitherto  been  considered  as  merely  con- 
ventional.    For  tl^e  most  part  the  uterus  has  but  one  cavity,  but 


54  OP  THE  UTERUS  AND  ITS  DEPENDENCIES. 

cases  of  double  uteri  are  upon  record;  thus  Lobstein  mentions 
tlie  case  of  a  woman  who  had  two  distinct  uteri.  Vallesneri 
dissected  a  female  in  whom  were  found  two  uteri;  the  orifice  of 
one  opened  into  the  vagina,  the  other  into  the  rectum. 

119.  Another  case  is  recorded  of  a  double  uterus,  in  a  woman 
"  who  died  of  peritoneal  inflammation  soon  after  the  birth  of  her 
fifth  child;  she  was  thirty  years  of  age.  Her  first  delivery  was 
laborious;  the  three  succeeding  ones  natural.  With  the  fifth  she 
died  soon  after  its  delivery.  The  uterus  was  found  to  consist  of 
two  lobes;  one  more  anterior  than  the  otber.  The  right  lobe 
had  evidently  contained  the  last  foetus.  It  was  probable  that  the 
first  children  were  contained  in  the  left  lobe.  The  vagina  was 
single."* 

120.  Lobstein  supposed  that  two  uteri  were  necessary  to 
super-foetation;  here  is  at  least  a  recent  instance  in  which  this 
did  not  take  place,  though  each  uterus  was  in  turn  impregnated. 
We  mention  these  instances  from  among  many  other  deviations  of 
this  organ,  which  may  truly  be  said,  to  have  almost  as  many 
conformations  as  any  other  important  viscera  in  the  body — to 
prove  this  we  need  but  consult  M.  Martin's  paper  on  this  subject, 
in  Revue  Med.  Vol.  3d.  p.  51. 

121.  Fallopian  Tubes.  The  uterus  may  be  farther  divided  into 
an  anterior,  and  posterior  surface,  and  into  two  sides.  The 
anterior  portion  of  the  uterus  is  rather  more  convex  and  thinner 
than  the  posterior,  and  is  subject  to  a  less  degree  of  distention — 
the  posterior  yielding  considerably  more,  during  the  progress  of 
gestation;  and  for  this  purpose  more  substance  is  given  to  it. 
From  each  side  of  the  uterus,  and  at  a  line  which  would  divide 
the  fundus  from  the  body,  a  tortuous  body  takes  its  rise;  and  is 
named  the  fallopian  tube:  it  is  hollow;  but  its  caliber  is  not  of 
a  aniform  width;  at  its  uterine  extremity,  the  opening  is  very 
small;  but  as  it  proceeds,  it  acquires  size,  and  eventually  termi- 
nates in  an  opening  of  some  capacity,  which  is  surrounded  by  an 
uneven  frill,  called  the  fimbria. 

122.  It  has  been  thought  by  some,  that  these  tubes  were  com- 
posed of  similar  tissues  with  the  uterus  itself;  it  is  denied  by 
others;  but  all  agree  that  they  enjoy  a  vermicular  motion.  Their 
linings  are  also  said  to  be  continuations  of  the  same  membrane 
which  lines  the  uterus;  but  I  have  already  called  this  in  question 
(111) — the  internal  membrane  of  each  tube  is  contracted  through 

*  Med.  and  Chirur.  Rev.  Sept.  1823. 


OP  THE  UTERUS  AND  ITS  DEPENDENCIES.  55 

its  whole  length  into  longitudinal  plicae;  and  furnishes,  by  means 
of  many  little  glands,  a  fluid  which  constantly  lubricates  its  sur- 
face. 

123.  Ovaries.  Near  to  the  abdominal  extremities  of  the  fallo- 
pian tubes  we  find  two  small  roundish  bodies  called  the  ovaria; 
these  glands,  if  we  may  so  term  them,  are  of  primary  importance 
to  the  genital  system  of  the  female.  By  them  is  given  the  first 
impulse  for  the  menstruous  secretion,  and  venereal  indulgence ; 
by  them  is  furnished  whatever  may  be  contributed  by  the  female, 
towards  the  formation  of  a  new  being.*  They  are  about  the  size 
of  a  common  nutmeg,  if  it  were  a  little  flattened;  and  when  cut 
into,  present  a  glandular  appearance — they  are  not  remarkably 
supplied  with  blood-vessels,t  nor  do  they  possess  much  sensibility 
— at  puberty  we  may  remark. upon  their  surface,  and  especially 
when  favourably  placed  between  the  eye  and  the  light,  a  number 
of  little  vesicular  bodies,  of  uncertain  number,  which  contain  a 
fluid,  capable,  it  is  said,  of  being  coagulated — these  are  the  ova. 
These  are  the  vesicles  of  De  Graaf,  and  are  in  number  from  ten 
to  twenty.  According  to  this  authority,  both  blood-vessels  and 
nerves  spread  themselves  upon  their  tunics,  in  a  manner  similar 
to  that  which  takes  place  upon  the  yolk  of  an  egg,  while  it  pre- 
serves its  attachment  to  its  ovary.  There  is  little  question  now, 
that  the  ovaries  furnish  the  ovules — at  least  if  any  dependence 
can  be  placed  upon  the  Observations  of  Prevost  and  Dumas. 

•  By  the  older  anatomists,  they  were  supposed  to  furnish  a  fluid  similar  to 
the  semen  of  the  male;  and  hence  were  termed,  testes  muliebres.  But  this 
analogy  is  altogether  gi-atuitous;  as  their  sti-ucture  Is  their^own,  and  peculiar, 
as  each  important  organ  must  be,  as  it  has  its  own  specific  role  to  perform,  in 
tlie  animal  body. 

f  Notwithstanding  this  poverty  of  vascularit}',  we  are  told  of  a  "  fatal  hemor- 
rhage from  the  rupture  of  the  fallopian  tube."  As  tlie  case  is  both  uncommon 
and  interesting,  we  will  give  it  as  recorded  in  the  Jour.  Univers. 

"  A  woman  who  lived  upon  bad  terms  with  her  husband,  one  evening  during  a 
violent  quarrel,  threw  a  chair  at  her  with  aU  his  force.  She  was  seized  with  a 
violent  colic  early  next  morning,  attended  by  an  alarming  purging  and  vomit- 
ing. The  belly  began  to  swell  after  these  symptoms  had  shown  themselves;  and 
after  thirteen  houKs  of  illness  died  in  convulsions.  In  consequence  of  suspicion 
that  she  had  died  of  poison,  the  body  was  taken  up  after  it  had  been  ten  d.ays 
buried,  and  carefully  examined,  by  order  of  the  proper  authorities.  It  was  found 
fresh,  and  free  from  contusions  or  lividity.  All  the  organs  in  the  head  and  chest 
were  found  sound,  as  well  as  the  ahmentary  canal;  but  the  belly  contained  a 
large  quantity  of  serous  fluid  and  coagula,  to  the  amount  of  eight  pounds  or 
more.  And  after  a  careful  search,  it  was  found  to  proceed  from  a  perforation 
in  the  right  fallopian  tube,  near  its  attachment  to  the  uterus." 


56  OP  THE  UTERUS  AND  ITS  DEPENDENCIES. 

They  declare  they  always  exist  in  the  ovaries  of  the  adult  female; 
but  cease  to  be  formed  in  old  age.  Animals  that  copulate  at  all 
seasons,  have  them  constantly  during  the  period  they  are  capable 
of  being  fecundated;  while  such  as  have  a  slated  period,  as  once 
a  year,  only  have  them  during  the  period  of  heat.  When  these 
are  displaced  by  either  fecundation  or  otherwise,  they  leave 
evidences,  that  they  occupied  certain  portions  of  the  surface  of 
the  ovaria. 

124.  We  may  also  remark  upon  the  face  of  the  ovarium,  a 
number  of  little  spots,  which,  from  their  colour,  are  named 
corpora  lutea;  these,  until  lately,  were  supposed  to  be  the  cica- 
trices of  removed  ova;  but  Sir  Everard  Home*  has  pretty 
satisfactorily  ])roved,  that  these  marks  exist  previously  to  impreg- 
nation; and  that  they  have  no  less  a  destiny,  than  to  furnish  the 
ovum,  and  prepare  it  for  impregnation.  In  the  virgin  state,  he 
declares  a  corpus  luteum,  to  be  a  solid,  compact,  glandular  body; 
and  when  the  ovum  is  liberated,  the  cavity  it  leaves  is  filled  with 
blood;  which,  after  awhile  is  absorbed,  and  a  small  pit  remains. 

125.  Dr.  Plagge,  of  Bentheim,  has  lately  been  investigating 
the  formation  of  the  ovum  in  the  mammalia.  He  entirely  agrees 
with  Sir  E.  Home  and  Mr.  Bauer,  as  to  the  formation  of  the 
ovum  in  the  ovary  before  impregnation;  but  he  thinks  he  has 
discovered,  that,  instead  of  being  formed  in  the  corpus  luteum, 
as  affirmed  by  these  gentlemen,  the  ovum  as  well  as  the  corpus 
luteum,  is  formed  in  the  vesicles  of  De  Graaf;  and  that  the  cor- 
pus luteum  bears  the  same  relation  to  the  ovum  in  the  ovary,  as 
the  placenta  does  afterwards  in  the  uterus.  He  observed,  that  a 
little  areola  first  appears  on  the  membrane  of  the  vesicle ;  and 
not  long  afterwards,  the  rudiment  of  the  future  ovum  may  be 
seen  like  a  grey  speck  in*  the  middle  of  this  areola,  and  the  in- 
side of  the  vesicle.  After  the  rudiment  has  increased  till  its 
diameter  is  equal  to  three  lines,  (in  the  cow,)  the  corpus  luteum 
begins  to  appear  on  the  peduncle  of  the  rudiment,  betwixt  it 
and  the  membrane  of  the  vesicle,  and  the  ovum  is  thus  gradually 
pushed  towards  the  surface  of  the  ovary,  to  be  impregnated.t 

126.  The  whole  of  the  abdominal  portions 'of  the  uterus 
namely,  the  fundus  and  body,  are  covered  with  peritoneum — 
and  as  it  passes  from  the  sides  of  this  organ,  it  forms  a  duplication 
towards  the  lateral  portions  of  the  pelvis;  and  makes  what  has 

•  See  Phil.  Trans,  years  1817  and  1819.  f  Jour.  Complcmcnta'ire,  &c. 


OF  THE  UTERUS  AND  ITS  DEPENDENCIES.  57 

been  termed  the  broad  ligaments — each  of  these  ligaments  has 
an  anterior  and  a  posterior  portion  or  pinion — in  the  anterior 
pinions,  the  fallopian  tubes  are  included  ;  and  in  tlie  posterior,  the 
ovaria. 

127.  The  round  ligaments,  two  in  number,  originate  from  the 
superior  lateral  parts  of  the  womb,  and  run  in  the  doublings  of 
the  broad  ligaments;  they  then  rise  to  the  brim  of  the  pelvis, 
pass  over  it  through  the  abdominal  rings,  and  lose  themselves,  as 
it  were,  in  the  groins.  These  ligaments  are  extremely  vascular 
during  pregnancy;  and  it  is  to  the  engorgement  of  them,  that 
Baudelocque  attributes  the  pain  the  woman  sometimes  feels  in 
these  parts,  as  gestation  advances.  These  two  sets  of  ligaments, 
have  been  supposed  to  give  support,  or  permanency  of  situation 
to  the  uterus;  if  this  be  the  design  of  them,  it  must  be  confessed 
they  perform  their  duties  in  a  very  inefficient  manner — for  it  is 
well  known  to  every  accoucheur,  that  nothing  can  be  more  un- 
certain, than  the  situation  of  this  organ;  for  every  change  in  the 
abdominal  viscera,  every  alteration  in  the  contents  of  the  bladdq^, 
and  rectum,  imposes  upon  it  a  new  position.  Mr.  Charles  Bell 
has,  however,  made  a  new,  and  what  he  seems  to  think,  an  im- 
portant suggestion,  as  to  the  offices  of  the  round  ligaments;  he 
supposes,  they  give  rise  to  a  number  of  muscular  fibres,  which 
perform  a  very  important  role  in  the  economy  of  gestation,  and 
of  labour;  while,  at  the  same  time,  they  perform  the  offices  of 
tendons,  rather  than  of  ligaments,  I  shall  refer  the  reader,  for  a 
consideration  of  Mr.  B.'s  opinions  upon  this  subject,  to  "Essays 
upon  various  subjects  connected  with  Midwifery,"  by  the  author, 
p.  461  et  seq. 

128.  The  uterus  is  supplied  with  blood-vessels  from  the  sper- 
matics  and  hypogastrics.  These  arteries  are  divided  into  two 
orders  by  some — the  first  supplies  the  substance  of  this  organ, 
by  penetrating  it  at  the  neck;  the  second,  are  those  given  off 
by  the  aorta,  or  emulgents;  and  after  supplying  the  ovaries 
and  broad  ligaments,  run  to  the  sides  of  the  uterus  itself.  The 
anastamoses  of  these  arteries  are  very  frequent,  and  the  two 
sides  of  the  uterus  reciprocate  in  their  distribution  and  union — 
thus,  the  arteries  of  the  right  side  unite  very  frequently,  and  inti- 
mately, with  those  of  the  left;  and  while  those  from  the  fundus  join 
with  those  of  the  cervix.  They  pass  in  such  manner,  as  to  be  much 
convoluted,  and  to  suffer  strong  compression  from  the  substance 

8 


58       OP  THE  EFFICIENT  AND  FINAL  CAUSE  OF  THE  MENSES. 

or  tissue  through  which  they  are  transmitted.  The  veins  observe 
a  similar  distribution,  and  eventually  pass  on  the  internal  ilise 
and  ovarian  veins.  The  intercostal,  the  renal  plexus,  and  sacral, 
furnish  it  with  nerves.  Mr.  Hawkins  informs  us,  that  "the 
nerves  of  the  human  uterus  are  supplied  from  six  different  plex- 
uses. The  spermatic  plexus  within  the  abdomen;  the  great 
hypogastric  plexus  between  the  common  iliac  arteries;  and  four 
within  the  pelvis;  two  of  which  are  situated  on  each  side  of  the 
uterus.  All  of  these  Jiave  the  peculiar  appearance  of  the  sympa- 
thetic nerve,  and  they  are  intimately  connected  with  all  the  other 
nerves  of  the  viscera."*  It  is  also  most  abundantly  provided 
with  lymphatics.t  Having  thus,  in  a  cursory  manner,  given  the 
anatomy  of  the  uterus,  it  would  seem  proper  that  its  functions 
should  next  be  considered;  and  first — 


CHAPTER  IV. 

OP  THE  EFFICIENT  AND  FINAL  CAUSE  OP  THE  MENSES. 

129.  By  menses,  we  mean  "  a  periodical  discharge  of  a  colour- 
ed fluid  resembling  blood,  happening  every  lunar  month;  com- 
mencing at  puberty,  and  continuing  until  about  the  forty-fifth  or 
even  fiftieth  year,  unless  interrupted  by  pregnancy,  suckling,  or 
disease." 

130.  It  was  formerly  a  matter  of  doubt  from  whence  this  dis- 
charge proceeded;  some  supposed  it  came  from  the  uterus  itself, 
and  others  from  the  vagina,  or  both.  This  question  is  now  put 
to  rest;  INIorgagni,  Dr.  William  Hunter,  and  others,  having  seen 
it  proceed  from  the  os  uteri,  in  cases  of  procidentia.  It  was  also 
a  matter  of  much  uncertainty,  which  class  of  blood-vessels  fur- 
nished this  fluid:  Ruysch  declared  it  to  be  from  the  arteries;  Ve- 
salius  from  the  veins;  and  Simpson  from  certain  appropriate  si- 
nuses. If  the  views  I  shall  take  of  this  interesting  phenomenon 
be  correct,  namely,  its  being  a  secretion,  it  will  be  found  to  pro- 
ceed, most  probably,  as  Ruysch  supposed,  from  the  arteries,   as 

•  rhilosoph.  Trans.  1825.  p.  70.         \  Cniikshank  on  the  Ljinpliatics. 


OF  THE  EFFICIENT  AND  FINAL  CAUSE  OF  THE  MENSES.       59 

all  the  secretions,  so  far  as  we  yet  know,  with  the  exception  of 
the  liver,  are  performed  by  arteries,  * 

131.  It  is  uncertain  who  first  suggested  the  idea,  that  themen- 
struous  discharge  is  a  secretion— the  credit  of  it  has  been  given 
to  Haller,  Bordeu,  Hunter,  and  Saunders— the  latter  unquestion- 
ably taught  it  publicly  in  1784,  and  how  long  before,  I  cannot 
ascertain  ;  but  this  is  of  little  consequence  now. 

132.  For  by  the  kindness  of  my  friend.  Dr.  Coxe,  I  have  as- 
certained that  the  doctrine  of  secretion  is  of  pretty  ancient  date. 
It  is  mentioned  by  Ramazzini  in  unequivocal  terms  as  a  secre- 
tion, as  the  following  passage  declares: — "Il-y-a  tout  lieu  de 
croire  que  le  sang  des  regies  a  quelque  qualite  maligne  etcachee; 
et  on  lui  a  donne  a  juste  titre  le  nom  de  secretion  et  excretion." 
In  this  extract,  the  term  "  secretion,"  appears  to  be  familiarly 
used;  and  one  most  probably  employed  in  common  parlance. 
And  Fourcroy,  the  translator  of  this  work  from  the  Latin,  in  a 
note  to  a  part  of  the  paragraph  from  which  the  above  extract  is 
taken,  says,  "Rien  cependant  n'etoit  plus  naturel,  sans  avoir  re- 
cours  aux  phenomenes  chymiques,  que  de  concevoir  le  flux  des 
regies,  comme  une  secretion  qui  a  son  organe,  ses  periods 
reglees,  sa  marche  et  son  department,  ainsi  que  toutes  les  autres 
secretions."!  Ramazzini's  work  was  first  published  in  1700; 
consequently  the  suggestion  of  the  menses  being  a  secretion  can- 
not belong  to  either  Haller,  Bordeu,  or  Hunter;  indeed,  it  would 
seem  from  the  manner  in  which  it  is  mentioned,  to  have  been 
taught  before  this  period,  as  no  claim  of  originality  is  preferred. 

133.  Independently  of  the  evidence  derived  from  the  structure 
and  diseases  of  the  uterus,  that  the  menses  are  the  result  of  a  se- 
cretory process  we  are  to  regard  the  appearances  of  the  dis- 
charged fluid  itself,  as  confirmatory  of  the  suggestion.  This  dis- 
charge must  be  either  a  portion  of  the  common  mass  of  blood  as 
it  circulates  at  large  in  the  system,  or  it  must  have  undergone 
some  change  during  its  separation  from  the  common  mass — if  the 
former,  it  should  exhibit  the  appearance  of  blood  detracted  from 
any  other  part  of  the  body  by  opening  a  vessel  for  the  purpose ; 

*  The  truth  of  this  last  assertion,  however,  has  been  lately  called  in  question 
by  Dr.  Holland,  from  Mr.  Abernethy  having'  met  with  an  instance  of  the  secre- 
tion of  bUe,  where  there  was  no  vena  porta;  and  that,  in  the  whole  of  the  mollus- 
cjE,  the  liver  is  very  large,  and  is  supphed  by  the  aorta  alone.— Zfe*.  Holland  on 
the  Physiology  of  the  Fostus,  &c. 

f  Ramazzini,  Essai  siu*  les  maladies  des  artisans,  ti-aduit  du  Latin,  par  M.  De 
Fouixroy,  p.  215. 


60        OF  THE  EFFICIENT  AND  FINAL  CAUSE  OF  THE  MENSES. 

but  this  is  not  so  ;  if  the  latter,  it  is  probable  that  it  has  been  eli- 
minated by  that  process  termed  secretion.  This  opinion  is  far- 
ther strengthened  by  the  follovving  considerations  of  the  physical 
properties  of  the  fluid  itself:  1st.  Its  colour  is  between  the  ar- 
terial and  venal  blood;  being  less  brilliant  than  the  former,  and 
more  florid  than  the  latter:  2d.  It  never  separates  into  parts; 
blood  drawn,  or  evacuated  from  any  other  part  of  a  healthy  body, 
does  separate  in  a  short  time,  into  its  principal  component  parts: 
3d.  It  never  coagulates,  though  kept  for  years;*  while  other 
blood,  when  free  from  disease,  quickly  does,  when  exposed  to 
the  influence  of  the  air:  4th.  Its  odour  is  remarkably  distinct 
from  that  of  the  circulating  mass;  and  it  is  less  disposed  to  pu- 
trefaction. 

134,  It  is  thought  by  some,  to  differ  materially  from  common 
blood,  from  it  not  possessing  fibrin;  of  this  I  cannot  speak  with 
certainty;  but  I  am  disposed  to  believe,  that  this  part  of  the 
blood  has  only  undergone  a  change,  during  elaboration;  more  es- 
pecially, as  the  coagulating  lymph  is  always  found  to  accompany 
the  red  globules,  whenever  blood  has  been  accidentally  extrava- 
sated,  or  designedly  drawn;  my  reasons  for  thinking  that  the  fi- 
brin of  the  blood  has  only  suffered  an  alteration  of  property,  and 
that  it  is  constantly  present  in  the  menstruous  blood,  but  is  alter- 
ed are,  that  in  many  instances,  nothing  more  is  necessary  to  this  ef- 
fect, than  the  establishment  of  some  peculiar  arterial  action — 
thus  we  find  in  certain  kinds  of  small-pox,  fevers  termed  putrid, 
scurvy,  &c.  the  blood  loses  the  power  of  coagulation;  the  blood 
of  those  who  die  from  lightning,  blows  upon  the  stomach,  &c.  it 
is  said,  that  the  coagulating  lymph  loses  the  capacity  to  coagulate 
— therefore,  the  mere  absence  of  coagulability,  is  not  sufficient  to 
prove  the  absence  of  fibrin. 

135.  In  this,  nature  has  shown  her  beneficence;  for  to  what 
wretchedness  would  the  woman  be  doomed  at  each  menstrual 
period,  did  it  retain  its  property  of  coagulation?  Mr.  Hunter 
thought  that  the  property  of  coagulatitjn  was  lost  from  the  blood 
losing  its  living  principle  during  the  secretion — but  to  this  we 
cannot  subscribe;  as  this  fluid,  as  has  already  been  noticed,  is 
thought  to  resist  putrefaction  longer  than  common  blood. 

*  My  friend  Di".  Physick  informs  me,  that  Dr.  Clark,  of  London,  used  to  ex- 
hibit a  vial  of  menstruous  blood  which  had  long  been  in  his  possession,  but 
which  had  never  separated  into  its  component  parts. 


OF  THE  EFFICIENT  AND  FINAL  CAUSE  OF  THE  MENSES.        61 

136.  I  have  stated  in  the  definition  of  "menses,"  that  it  first 
takes  place  at  puberty,  or  that  period  at  which  the  animal  is  ca- 
pable of  propagating  its  species — this  period  must  vary  as  it  may 
be  influenced  by  climate,  constitution,  and  modes  of  life;  always 
being  earlier  in  hot,  than  in  cold  countries;  sooner  in  cities  than 
in  the  country,  &c.  Before  they  make  their  appearance,  they 
almost  always  announce  themselves,  in  the  altered  appearance  of 
the  female-— the  mammse  increase  in  size;  the  voice  undergoes  a 
slight  change;  the  pubes  are  covered  with  hair;  and  the  best  pro- 
portions the  individual  is  susceptible  of,  is  now  suddenly  and 
successfully  developed.  The  mind  is  also  replete  with  changes; 
puerile  amusements  now  yield  to  maturer  enjoyments,  and  ra- 
tional inquiry;  capricious  attachments  give  place  to  sincere,  un- 
affected, and  permanent  friendship;  in  a  word,  a  new  creature 
almost  seems  to  be  suddenly  formed.  Besides  the  physical  and 
moral  changes  just  spoken  of,  there  are  other  circumstances, 
which  mark  the  pubescent  period  to  be  near  at  hand — such  as 
head-ache,  dulness  of  the  eyes,  pains  in  the  pelvic  region,  lassi- 
tude, whimsical  appetite,  slight  leucorrhoea,  &c.  and  after  these 
have  continued  a  longer  or  shorter  time,  they  suddenly  depart, 
and  a  discharge  of  a  small  quantity  of  fluid  from  the  vagina,  and 
this  not  necessarily  coloured  at  first,  is  found  to  have  taken  place. 
The  last  named  circumstance  is  worthy  of  attention;  as  it  will 
serve  to  explain  those  cases  of  impregnation  which  are  said  to 
have  taken  place  previously  to  the  eruption  of  the  menses. 

137.  The  menstruous  period  is  usually  from  four  to  six  days; 
and,  during  this  time,  from  four  to  six  ounces  of  fluid  are  dis- 
charged— in  this  there  must  necessarily  be  some  variety;  depend- 
ing upon  constitution,  &c.  After  it  ceases,  the  woman  is  exempt 
from  a  repetition,  for  twenty-eight  days  or  a  lunar  month  less 
the  time  it  is  flowing;  but  at  which  time  it  returns  with  distin- 
guished regularity— so  much  so  indeed  with  some  women,  as 
to  enable  them,  not  only  to  indicate  the  day,  but  also  the  hour — 
during  the  flow,  the  appetite  with  some,  becomes  capricious; 
they  are  languid,  pale,  or  hectically  florid;  a  dark  stripe  most 
frequently  may  be  observed  below  the  eyes;  and  with  many,  a 
dragging  sensation  is  felt  about  the  hips  and  loins,  during  the 
whole  period. 

138.  In  this  manner  are  women  subject  to  this  flux,  until  be- 
tween the  fortieth  and  fiftieth  years;  at  which  time  they  cease, 
never  to  return.      For  the  most  part,  as  the  period  of  cessation  ap- 


62  OF    LUNAR    INFLUENCE. 

proaches  they  fail  in  their  wonted  regularity — sometimes  the 
period  is  protracted  to  six  or  seven  weeks,  and  then  instead  of 
five  or  six  ounces  being  evacuated,  there  may  be  a  loss  of  twenty 
or  thirty;  or  there  may  be  merely  a  show,  as  it  is  termed — at 
other  times  the  period  may  be  anticipated  by  as  many  days  as  it 
had  exceeded  before;  and  the  discharge  may  be  as  vague  as  I 
have  just  mentioned. 

139.  I  have  known  several  instances,  where  the  eruption  of 
the  menses  was  constantly  preceded  by  strong  hysterical  parox- 
ysms, of  greater  or  less  permanency;  the  menses  would  now  ap- 
pear, and  instantly  the  system  would  be  tranquillized,  and  the 
woman  return  to  her  ordinary  state  of  health.  In  one  case,  a 
severe  pruritus  accompanied  this  convulsive  state,  to  the  great 
annoyance  of  the  poor  young  woman  who  was  the  subject  of  it.* 

140.  From  the  earliest  records  of  medicine  to  the  present  day, 
the  ingenuity  of  the  philosopher  has  been  exercised  to  point  out 
the  efficient  cause  of  this  peculiar  habit  of  the  human  female;  I 
shall  therefore  cursorily  pass  in  review  the  various  hypotheses 
which  have  been  invented  for  this  purpose,  and  first 

Sect.  I. — Of  Lunar  Influence. 

141.  The  influence  of  the  moon  was  very  early  assigned  as  the 
efficient 'cause  of  menstruation;  from  either  the  real  or  supposed 
efiects  of  this  luminary  upon  tides  and  diseases,  it  was  easy  to 
believe  it  might  have  a  power  or  control  over  some  of  the  healthy 
functions  of  the  body;  and,  as  the  menstruous  flux  was  periodi- 
cal, and  observed  a  lunar  period,  or  interval,  it  was  no  great 
stretch  of  the  imagination,  to  suppose  its  return  connected  with 
the  movements  of  this  body :  this  opinion  is  not  entirely  exploded 
at  the  present  mfoment;  though  to  destroy  this  hypothesis,  it  is 
only  necessary  to  state  the  fact,  that  there  are  women  menstrua- 
ting promiscuously  every  day  of  the  year,  and  every  hour  of  that 
day.  Galen,  at  an  early  period,  saw  the  weakness  of  this  scheme, 
and  accordingly  invented  another;  namely, 

*  This  young  woman  was  perfectly  relieved  from  these  disagi-eeable  symp- 
toms, by  camphor  in  ten  ^-ain-doses,!  at  the  commencement  of  the  menstruous  pe- 
riod, and  hberally  washing  the  parts  in  tlie  interval  with  a  strong  solution  of  borax. 

t  The  writer  of  the  "Criiical  Analysis  of  Dr.  Dewees  on  Midwifery,"  in  the  London  Med.  &. 
rhys.  Jour,  for  July,  p.  72,  says,  "We  should  be  unwilling  to  give  ten  grains  at  a  dose  (of  camphor) 
without  having  first  tried,  by  the  exhibition  of  a  smaller  quantity,  the  power  of  the  patient  to  bear 
the  remedy." 

I  can  assure  the  gentleman,  that  I  rarely,  if  ever,  give  this  medicine  in  smaller  doses ;  nor  have 
I  ever  witnessed  the  smallest  inconvenience  to  follow,  which  was  attributable  to  the  largeness  of 
the  dose.    Idiosyncrasy  may  make  any  quantity  improper. 


THE  GENERAL  PLETHORA  DOCTRINE.  fi3 

Sect.  II.  —  The  General  Plethora  Doctrine. 

142.  This  hypothesis  has  higher  claims  to  our  attention,  than 
the  one  we  have  just  been  considering;  for  it  is  both  ingenious, 
and  plausible.  He  began  with  stating,  that  women  were  more 
disposed  to  plethora  than  men;  2d.  That  to  get  rid  of  this  super- 
abundance of  blood,  some  outlet  was  necessary,  and  that  this 
outlet  was  the  uterus;  3d.  That  this  state  of  fulness  was  essential 
to  the  female  system,  as  it  must  make  provision  for  the  child, 
while  in  utero,  as  well  as  provide  it  sustenance  after  it  is  born;  and 
that  these  objects  v/ere  effected  by  the  suppression  of  this  dis- 
charge during  pregnancy  and  suckling;  4th.  That  when  the  uterus 
failed  in  destroying  this  plethora,  some  other  part  performed  a 
vicarious  office,  and  gave  issue  to  the  blood:  hence  haemorrhages 
from  the  lungs,  bowels,  ulcers,  &c. ;  5th.  That  when  this  evacu- 
ation failed  to  appear  under  ordinary  circumstances,  the  quantity 
of  blood  was  below  the  ordinary  standard;  and  that  it  could 
only  be  recalled  by  such  remedies  as  would  increase  the  measure 
of  this  fluid. 

143.  To  the  first  of  his  positions,  it  may  safely  be  said,  that 
strong  doubt  must  be  entertained  of  the  fact;  for,  though  women 
may  exercise  less  than  men,  they  perspire  more;  and  their  ingesta 
is  certainly  less. 

144.  And  if  there  be  a  plethora,  it  must  be  occasioned  by  five 
or  six  ounces  of  blood;  yet  it  is  well  known,  that  if  five  times 
that  quantity  were  drawn  just  before  the  period  was  expected,  or 
during  its  flow,  that  it  would  neither  interrupt  the  eruption,  nor 
diminish  the  quantity  that  would  otherwise  be  expended.  Of 
this  I  am  certain,  from  the  following  facts:  many  years  since,  I 
witnessed  a  singular  periodical  haemorrhage  from  the  ear  of  a 
young  lady,  which  was  of  several  months'  duration;  it  woukf 
commence  at  about  11  o'clock,  A.  M.  every  day,  with  the  utmost 
regularity,  and,  after  giving  issue  to  an  ounce  or  two  of  blood, 
it  would  spontaneously  stop,  and  not  recur  until  the  same  hour  of 
the  next  day:  yet  this  young  lady  menstruated  with  the  utmost 
regularity,  both  as  to  period  and  quantity.  It  may  not  be  unin- 
teresting to  state,  that  this  affection  was  cured  by  the  application 
of  a  blister  near  the  part,  after  very  many  other  remedies  had 
fruitlessly  been  tried.  Another  case  fell  under  my  observation, 
which  goes  still  farther  to  prove,  that  general  plethora  has  no 
agency  in  the  production  of  the  catamenia.     A  young  lady  asked 


64  THE  GENERAL  PLETHORA  DOCTRINE. 

my  advice  for  a  daily  discharge  of  blood  from  the  anus,  of  several 
years'  continuance:  she  would  lose  very  frequently  from  a  half 
pint  to  a  pint  at  a  time,  and  smaller  quantities  almost  daily;  she 
of  course  was  feeble,  and  far  removed  from  plethora ;  yet  she 
menstruated  regularly,  and  never  employed  less  than  a  week  for 
the  discharge. 

145.  To  the  second  it  may  be  answered,  that  men,  however 
plethoric,  have  no  such  compensating  discharge.*  To  the  third 
it  may  be  declared,  the  means  are  not  adequate  to  the  end  :  for 
the  embryo  would  not  require,  for  a  long  time,  anything  like 
five  or  six  ounces  of  blood  for  its  support;  and,  at  a  more  ad- 
vanced period  of  gestation,  it  would  be  altogether  insufficient. 
With  respect  to  its  subserviency  to  lactation,  how  totally  insuffir 
cient  would  it  be  for  a  healthy,  or  even  a  very  feeble  infant! 
The  fourth  I  must  protest  against,  as  a  fact;  for  in  all  good  faith, 
I  avow,  that  in  moi^e  than  forty  years'  practice,  I  have  never 
witnessed  an  unquestionable  case  of  this  kind.  And,  as  regards 
the  fifth,  the  daily  experience  of  almost  every  practitioner,  must 
be  set  in  opposition  to  it ;  for,  though  we  very  frequently  employ 
stimulants  for  the  restoration  of  the  menstruous  secretion,  yet 
they  do  not  act  by  filling  the  blood-vessels,  but  by  increasing 
their  activity  ;  but  are  we  not  obliged  almost  always  to  employ 

*  Dr.  Burdach,  a  German  writer,  in  a  work  entitled  "  Phj'siology  as  an  Ex- 
perimental Science,"  considers  menstruation  as  depending  upon  causes  either 
general  or  local.  "  Its  general  cause,"  he  says,  "  is  evidently  to  be  found  in  the 
circumstance  of  the  blood  being  so  abundantl}'  generated  by  the  female  system, 
as  to  produce  every  four  weeks  an  excess,  which  requires  to  be  in  this  manner 
evacuated."  To  prove  this,  he  has  but  renewed  the  old  doctrine  of  Galen,  just 
noticed,  and  at  once  assumes  a  principle  which  remains  to  be  proved ;  namely, 
that  the  female  system  generates  a  superfluous  quantity  of  blood,  and  re- 
quires to  be  removed  from  the  system  by  an  oiRce  of  the  uterus.  We  deny  that 
any  satisfactory  proof  to  have  yet  been  offered  of  this  assertion,  and  for  the 
reasons  assigned  above  ;  for  Di-.  B.  only  employs  the  arguments  just  mentioned 
to  sustain  this  hypothesis,  and  which,  we  think,  are  readily  disproved. 

Dr.  B.  accounts  for  this  tendency  to  plethora  in  the  female,  by  referring  it  to 
"  a  greater  activity  of  tlie  productive  powers  generally,  and  consequently  of 
sanguification  existing  in  the  female  than  in  the  male  system;  for  the  extent  of 
the  menstrual  discharge  has  an  immediate  relation  with  the  activity  of  the  pro- 
ductive powers."  This  we  utterly  deny,  as  we  have  known  many  very  pletlioric 
females  who  have  had  sparing  menses,  and  many  that  laboured  under  even  a 
suppression  of  them;  while,  as  we  have  already  observed,  we  have  seen  them 
abundant  in  debilitated  females. 


THE  GENERAL  PLETHORA  DOCTRINE.  65 

depleting  remedies  before  we  can  advantageously  use  tonics? 
and  do  they  not  sometimes  succeed  without  the  agency  of  stimu- 
lants? 

146.  The  doctrine  of  fermentation  of  the  chemists;  the  me- 
chanical solution  of  Dr.  Friend ;  the  preposterously  indelicate 
hypothesis  of  Le  Cat  and  Brown,  do  not  deserve  an  attempt  at 
refutation;  we  shall  consign  them  with  some  others,  to  "the 
tomb  of  all  the  Capulets,"  from  whence,  we  trust,  they  will  never 
be  recalled. 

147.  I  cannot,  however,  dismiss  this  part  of  my  subject,  with- 
out noticing  the  highly  ingenious  explanation  of  Dr.  Cullen,  by 
whom  it  was  taught  with  all  the  force  of  eloquence,  and  every 
charm  of  fancy;  and  its  plausibility,  and  speciousness,  was  such 
as  to  enlist  in  its  defence,  almost  all  the  teachers  in  Europe,  and 
not  a  few  in  America.     It  is  called  the  theory  of 

Sect.  III. —  Topical  Co7igestion. 

148.  Dr.  Cullen  supposes  that  the  body  is  developed  pretty 
much  in  the  order  of  necessity,  and  the  size  of  the  vessels  belong- 
ing to  the  part:  hence  the  head  and  superior  extremities  are 
first  unfolded;  then  the  lower  extremities;  and  lastly,  the  uterus. 
<<But,"  says  he,  "as  the  vessels  of  every  part  by  their  disten- 
tion and  growth,  increase  in  density,  and  thus  give  greater  re- 
sistance to  further  growth;  at  the  same  time,  by  the  same  resist- 
ance, they  determine  the  blood  in  greater  quantity  into  parts 
not  yet  equally  developed.  By  this  means  the  whole  system 
must  be  successfully  and  equally  evolved.  Upon  these  princi- 
ples, there  will  be  a  period  in  the  growth  of  the  body,  when 
the  vessels  of  the  uterus  will  be  in  equilibrium  with  the  other 
parts  of  the  system;  (md  their  constitution  may  be  such,  that 
their  distention  may  proceed  so  far  as  to  open  their  extremities, 
terminating  in  the  cavity  of  the  uterus,  so  as  to  pour  out  blood 
there;  or  it  may  happen,  that  a  certain  degree  of  distention  may 
be  sufficient  to  irritate  and  increase  the  action  of  the  vessels,  and 
thereby  produce  an  hsemorrhagic  effort,  which  may  force  the 
extremities  of  the  vessels,  with  the  same  effect  of  pouring  out 
blood." 

149.  In  either  way  he  accounts  for  the  first  appearance  of  a 
flow  of  blood  from  the  uterus  of  women.  In  order  to  this,  he 
does  not  suppose  any  more  of  a  general  plethora  in  the  system^ 


66  TOPICAL  CONGESTION. 

than  what  is  constantly  necessary  for  the  successive  evolution  of 
the  several  parts  of  it;  and  proceeds  upon  the  supposition,  that 
the  evolution  of  each  particular  part  must  necessarily  depend 
upon  plethora,  or  increased  congestion  in  its  proper  vessels. 
Thus  he  supposes  it  to  happen  with  respect  to  the  uterus;  but 
as  its  plethoric  state  produces  an  evacuation  of  blood  from  its 
vessels — this  evacuation  must  empty  these  vessels  more  especial- 
ly, and  put  them  again  into  a  relaxed  state  with  respect  to  the 
system.  This  empty  and  relaxed  state  of  the  vessels  of  the  uterus, 
will  give  rise  to  a  new  congestion,  till  they  are  brought  again  to 
that  degree  of  distention,  that  may  either  force  their  extremities? 
or  produce  a  new  hsemorrhagic  effort  that  may  have  the  same 
effect.  Thus,  an  evacuation  of  blood  from  the  uterus,  being  once 
begun  by  the  causes  just  mentioned,  it  must  by  the  operation  of 
the  same  causes,  return  after  a  certain  period,  and  must  continue 
to  do  so  till  particular  circumstances  occasion  a  considerable 
change  in  the  constitution  of  the  uterus.  What  determines  the 
period  to  nearly  a  month,  he  cannot  explain;  but  supposes  it  to 
depend  upon  a  certain  balance  between  the  vessels  of  the  uterus 
and  those  of  other  parts  of  the  body.  This  must  determine  the 
first  periods;  and  when  it  does  so,  it  can  be  understood,  that  a 
considerable  increase  or  diminution  of  the  quantity  of  blood  in 
the  whole  system  will  have  but  little  effect  in  increasing  or  dimin- 
ishing the  quantity  distributed  to  the  uterus.  And  when  this 
evacuation  has  been  repeated  for  some  time  at  regular  periods,  it 
may  be  supposed  that  the  power  of  habit,  which  so  readily  takes 
place  in  the  animal  system,  may  have  a  great  share  in  determin- 
ing the  periodical  motions  of  the  uterus. 

150.  Upon  this  celebrated  hypothesis,  I  shall  beg  leave  to  ob- 
serve, first,  that  he  has  admitted  more  causes  than  are  necessary 
to  account  for  the  phenomena — thus  at  one  moment,  "  their 
distention"  is  such  "as  to  open  their  extremities,  terminating  in 
the  cavity  of  the  uterus,  so  as  to  pour  out  blood  there ;"  in  an 
instant  after,  he  conjectures,  "  that  a  certain  degree  of  distention 
may  be  sufficient  to  irritate  and  increase  the  action  of  the  vessels, 
and  thereby  produce  an  hasmorrhagic  effort,  which  may  force  the 
extremities  of  the  vessels,  with  the  same  effect  of  pouring  out 
blood."  Here  two  distinct  causes  are  assigned;  namely,  "dis- 
tention," and  an  "hsemorrhagic  effort,"  for  the  same  effect; — 
both  of  these  could  not  possibly  operate  at  the  same  time,  if  they 
be  distinct  agents;  and  if  they  be  not,  we  are  certainly  entitled 


TOPICAL  CONGESTION.  67 

to  be  informed,  in  what  they  differ ;  for  we  cannot  understand  what 
is  meant  by  an  hsemorrhagic  effort,if  it  be  distinct  from  such  a  de- 
gree of  distention,  as  shall  force  the  vessels  to  yield  blood.  2d.  That 
if  this  scheme  be  true,  the  menstruous  discharge  is  nothing  but  a 
common  haemorrhage;  for  here  are  vessels  distended  to  such  a  de- 
gree as  to  oblige  "their  extremities  terminating  in  the  uterus,  to 
2)0iir  out  blood  there;"  now,  what  are  we  to  understand  in  this 
instance  of  blood  being  poured  into  the  cavity  of  the  uterus,  differ- 
ent from  blood  being  poured  into  the  cells  of  the  lungs,  or  the  cavity 
of  the  stomach,  when  the  sides  or  extremities  oftheir  vessels  are  so 
forced  as  to  yield  their  contents?  We  see  none;  yet  the  appear- 
ance of  the  menstruous  blood  is  entirely  different  from  ha^mor- 
rhagic  blood. 

151.  Third.  Were  this  doctrine  true,  no  woman  could  possibly 
preserve  the  fruit  of  her  womb  to  the  full  period  of  utero-gesta- 
tion;  for  it  is  a  fact  as  well  ascertained,  as  any  connected  with 
our  history,  that,  so  soon  as  conception  takes  place,  an  increased 
flow  of  blood  to  the  uterus  takes  place;  now,  if  upon  common 
occasions,  much  less  blood  will  produce  such  a  "  distention,  or 
haemorrhagic  effort"  in  the  vessels  terminating  in  the  cavity  of 
the  uterus,  that  they  shall  pour  out  blood  there,  what  is  there  to 
prevent  an  increased  quantity,  the  consequence  of  pregnancy, 
from  doing  the  same,  and  thus  deluging  at  once  the  delicate  and 
unsettled  ovum? 

152.  Fourth.  It  would  seem  in  some  measure  essential  to  this 
hypothesis,  that  "  habit"  should  exert  a  certain  influence,  to  en- 
sure the  periodical  returns  of  the  catamenia — it  can,  we  think, 
in  one  moment  be  shown  that  "habit"  has  not  the  smallest  agency 
in  the  production  of  this  discharge;  for  it  is  notorious  to  every 
body,  that  this  is  constantly  interrupted  in  married  women  for 
many  months  together — nine  montiis  of  pregnancy,  twelve  or 
even  eighteen  months  of  suckling;  during  the  whole  of  which 
time,  the  menses  do  not  make  their  appearance;  yet,  the  child 
is  no  sooner  taken  from  the  breast,  than  this  evacuation  establishes 
itself,  and  with  as  much  regularity  as  if  it  had  never  been  inter- 
rupted— since  then,  in  these  instances,  "habit"  has  had  no  influ- 
ence upon  the  first  return,  it  cannot  possibly  be  necessary  to  any 
number  of  returns. 

153.  From  what  has  just  been  said,  it  appears  that  hitherto 
nothing  satisfactory  has  been  advanced  upon  this  curious  subject 
— it  yet  remains  for  some  future  Haller  or  Hunter  to  enrich 
medical  science  with  a  rational  explanation  of  it. 


68  FINAL  CAUSE. 

Sect.  IV. — Final  Cause. 

154.  The  final  cause  of  the  menses  is  perhaps  enveloped  in 
some  obscurity;  but  of  this  we  know  at  least  one  incontrovertible 
fact;  namely,  that  the  healthy  performance  of  this  function  is  in 
some  way  or  other  connected  with  the  capacity  for  impregna- 
tion; as  no  well-attested  instance  is  upon  record,  where  this  has 
taken  place  in  a  female  who  never  had  had  this  discharge,  or 
even  when  it  was  not  of  a  healthy  character,  and  with  a  greater 
or  less  degree  of  regularity.  It  may  perhaps  be  said,  that  in  the 
instances  of  women  who  had  never  menstruated,  there  was  some 
imperfection  in  the  genital  organs;  and  this  perhaps  was  the  case 
pretty  uniformly.  I  know  it  was  so  in  one,  which  fell  under  my 
own  notice — a  young  lady  of  twenty-eight  years  of  age  had  never 
menstruated,  or  given  any  evidence  of  the  necessity  of  this  eva- 
cuation, as  she  very  uniformly  enjoyed  good  health  and  spirits. 
She  was,  however,  seized  with  an  inflammation  of  her  bowels,  and 
soon  became  alarmingly  ill;  I  was  requested  to  visit  her  in  con- 
sultation ;  and  as  she  never  had  menstruated,  and  as  she  suffered 
severe  periodical  pains  in  the  region  of  the  uterus,  it  was  supposed 
that  some  derangement  of  this  organ  might  be  the  cause  of  her 
present  suffering;  I  was  accordingly  requested  to  examine  her 
per  vaginam.  The  finger  passed  into  the  vagina  with  some  diffi- 
culty, but  the  uterus  was  readily  touched.  It  presented  to  the 
finger  a  size  not  exceeding  the  thumb  of  a  man;  and  its  neck  was 
as  slender  as  a  common  writing  quill,  and  about  half  an  inch  in 
length.  The  pubes  were  covered  with  the  usual  quantity  of 
hair,  and  the  mammae  were  pretty  well  developed — the  imper- 
fection in  this  case  consisted  most  probably,  in  the  want  of  size 
of  the  uterus  alone;  as  it  is  more  than  probable,  from  the  state 
of  the  breasts,  and  covering  of  the  pubes,  that  the  ovaria  were  not 
in  fault — moreover;  she  was  fond  of  mixed  society;  and,  I  have 
reason  to  believe,  she  was  ardently  attached  to  a  gentleman,  but 
refused  to  marry,  on  account  of  tlie  absence  of  the  menses.  She 
died  two  or  three  days  after  the  examination ;  but  leave  could 
not  be  obtained  to  inspect  the  body.* 

*  Since  this  time,  I  have  been  consulted  on  a  similar  case,  as  far  as  regards  the 
j^eneral  condition  of  the  female.  She  is  twenty-four  yeai'S  of  age;  rather  tall» 
and  apparently  enjoyinga  healthy  conformation.  She  has  never  felt  any  pain  or 
other  inconvenience  that  would  give  rise  to  the  opinion,  that  this  absence  of  the 
menses  was  owing  to  an  occlusion  of  the  vagina.  She  is  frequently  attacked  with 


FINAL  CAUSE.  69 

155.  Mr.  Renaudin  gives  an  account  of  a  woman  in  whom  the 
uterus  was  wanting.  The  subject  died  of  a  disease  of  the  stomach; 
had  never  menstruated ;  was  of  small  stature,  only  three  and  a  half 
feet  high;  imperfect  in  intellect;  breasts  not  developed.  The  ex- 
ternal genital  organs  were  well  formed ;  the  hymen  in  part  existed ; 
and  a  finger  introduced  into  the  vagina  encountered,  instead  of 
the  neck  of  the  uterus,  a  small  tubercle.  Between  the  bladder 
and  rectum,  instead  of  the  uterus,  there  was  a  kind  of  firm  cord 
about  the  size  of  a  quill,  communicating  at  one  extremity  with 
the  vagina,  and  also  with  the  fallopian  tubes.  These  tubes  were 
very  large,  and  formed  a  kind  of  sac,  where  they  opened  into  the 
vagina.  Some  traces  of  ovaria  were  faintly  observable.  The 
vagina  perfect;  the  neck  of  the  uterus  imperfectly  formed; 
the  body  and  fundus  altogether  wanting.  Thus  we  see  that  the 
want  of  a  uterus  is  by  no  means  unique;*  but  to  render  such  ac- 
counts interesting,  the  previous  history  of  the  subject  should  be 
pretty  well  known.  The  case  just  recorded  is  valuable,  because 
we  are  informed  of  the  smallness  of  the  body :  the  absence  of 
certain  functional  processes;  and  the  want  of  developement  of 
certain  parts  connected  with  the  genital  system,  together  with 
the  weakness  of  the  intellectual  faculties;  and  it  would  be  curi- 
ous to  compare  the  general  developements  of  the  body  and  mind, 
with  the  absence  of  the  principal  genital  organs,  t 

156.  But  cases  like  those  just  related  cannot  invalidate  the 
other  part  of  the  position ;  namely,  that  women  must  not  only 
menstruate,  but  must  menstruate  healthily  and  regularly,  to  in- 
sure impregnation.  Besides,  a  strong  analogy  is  presented  to  us 
in  the  economy  of  brutes — the  females  of  which  have  their  periods 
of  salacity;  at  this  time  they  have  a  copious  discharge  from  the 
vagina,  which  without  question  is  of  similar  import  with  the 
menses  of  the  human  female — it  is  not  a  mere  increased  flow  of 

severe  pain  in  the  region  of  the  spleen,  wliich  will  last  for  several  clays  tog-ether. 
She  also  suffers  greatly  from  headache,  palpitation  of  the  heart,  and  other  nei-- 
vous  symptoms.  The  mamms,  her  mother  informs  me,  are  well  developed, 
and  the  pubes  furnished  with  capiUi.  She  has  had  several  ehgible  offers  of  mar- 
riage; all  of  which  she  has  rejected,  from  an  opinion  that  it  would  be  dishonest 
to  marry  under  such  circumstances.  I  was  of  opinion  that  tliere  was  notliing 
to  be  done  in  her  case,  and  therefore  did  not  prescribe. 

*  Leuteaud  also  mentions  a  case  in  which  it  was  altogether  wanting  in  a  wo- 
man he  dissected.     Coitus  erat  difficilis. 

■J-  See  Archives  Generales. 


70  OP  CONCEPTION. 

the  natural  vaginal  discharge;  for  we  see  it  instantly  detected  by 
the  discriminating  olfactories  of  the  male. 

157.  It  may  be  asked,  why  are  the  menses  in  the  human 
female  coloured?  It  may  be  difficult  to  answer  this  question  satis- 
factorily; but  I  am  of  opinion,  that  one  of  its  uses  is,  to  adver- 
tise the  female  when  this  discharge  is  arrested,  that  impregnation 
has  most  probably  taken  place ;  and  thus  enable  her  to  make  the 
necessary  arrangements  for  the  period  of  becoming  a  mother. 
Were  this  discharge  not  coloured;  it  might  readily  be  mistaken 
for  an  increase  of  the  secretion,  natural  to  the  uterus  and  vagina 
— but  being  coloured,  this  error  could  not  well  take  place. 


CHAPTER  V. 


OF  CONCEPTION. 

158.  The  ingenuity  of  physiologists  has  invented  hundreds  of 
hypotheses  to  account  for  impregnation  in  the  human  siibject. 
The  views  of  the  supporters  of  these  various  notions  may,  how- 
ever, be  reduced  to  a  few  general  heads: — 1st.  They  may  be  di- 
vided into  those  who  suppose  the  male  semen  to  be  directly 
conve3'ed  to  the  ovaries,  by  being  urged  by  the  powers  of  the 
male  apparatus  through  the  neck  of  the  uterus,  into  its  cavity; 
and  from  thence  to  be  transported  by  some  inherent  power  of 
the  uterus  to  these  bodies.  2d.  Into  those  who  supposed  this 
ground  not  tenable;  and  who  declared  the  semen  is  first  absorbed 
from  the  vagina,  and  carried  eventually  to  the  ovaries,  through 
the  medium  of  the  circulation.  3d.  Into  those  who  believe  the 
semen  makes  an  impression  upon  the  labia,  vagina,  or  the  uterus; 
and  that  impregnation  takes  place  by  the  ovaria  sympathizing 

*  We  employ  this  term  to  signify,  the  successful  application  of  the  male 
semen,  to  whatever  is  furnished  by  the  female,  for  the  continuation,  or  propa- 
gation of  the  species.  Velpeau  makes  "the  function  of  reproduction  of  the 
human  species"  consist,  1.  Of  generation,  or  the  formation  of  the  germ;  2.  Of 
fecundation,  or  the  vivification  of  tlie  germ;  3.  Oi conception,*  or  the  retention 
of  the  vivified  germ;  4.  0(  gestation  or  pregnancy,-  5.  Of  parturition,  or  the 
expulsion  of  the  ovum. 

*  Velpeau  defines  conception  to  be  thnt  change  or  changes  which  takes  place  between  the  instant 
of  vivification,  and  the  period  at  which  the  germ  shows  evidence  of  developement. 


OF  CONCEPTION.  71 

with  this  impression.  4th.  Into  those  who  believe  in  the  direct 
conveyance  of  the  semen,  after  its  being  taken  up  from  the  labia 
pudendi  or  vagina  by  a  set  of  vessels,  whose  whole  duty  is  to 
convey  it  to  the  ovaries. 

159.  Against  the  first  opinion  it  may  be  urged,  that  many  well- 
attested  instances  have  occurred,  where  it  was  impossible  that 
the  extremity  of  the^male  urethra  could  be  placed  in  direct  ap- 
position to  the  OS  tincae,  so  as  to  receive  the  male  semen  from  it 
by  a  vis  a  tergo,  (a  sine  qua  non  to  this  hypothesis,)  1st.  because 
of  the  entire  occlusion,  in  some  instances,  of  the  os  externum,  by 
a  too  dense  hymen,  cicatrices,  or  the  vagina  terminating  in  the 
rectum;  consequently  the  penis  could  not  enter  it;  j^et  impreg- 
nation has  taken  place  under  such  conformations.*  2d.  By  the 
male  urethra  not  terminating  at  the  extremity  of  the  glans  penis, 
but  beneath  it,  at  the  posterior  extremity  of  the  frsenum;  by  the 
urethra  being  obstructed  by  strictures;  by  that  canal  terminating 
at  the  junction  of  the  scrotum  with  the  body  of  the  penis;  conse- 
quently destroying  the  impetus  the  semen  derived  from  the  eja- 
culatory  powers  of  the  male  organs,  &c. 

160.  To  the  second  it  may  be  objected,  that  if  the  semen 
were  absorbed  by  the  lymphatics  of  the  vagina,  it  would,  like 
every  other  substance  subjected  to  their  influence,  be  changed; 
consequently  could  not  impregnate  an  ovum,  as  it  is  no  longer 
pure  semen.  To  this,  it  is  true,  it  may  be  answered,  that  the 
very  changes  imposed  upon  the  semen  by  the  absorbents,  may 
be  essential  to  fecundation.  But  this  would  be  flying  in  the  face 
of  the  experiments  of  Spallanzini,  who  found  that  the  semen 
itse(f  was  absolutely  necessary  to  impregnation. 

•  The  celebrated  Louis  mentions  the  case  of  a  congenital  imperfection  of  the 
external  org-ans  of  generation  in  a  certain  young  lady  who  menstruated  per 
anum.  She  was  demanded  in  marriage  by  a  young  man  to  whom  she  was  at- 
tached. After  much  resistance  she  confessed  to  liim  the  secret.  In  the  delirium 
of  his  passion,  he  supphcated  her  to  consent  to  then-  union  in  the  only  practi- 
cable way;  to  which  she  consented;  became  pregnant,  and  was  dehvered  of  a 
well-formed  child  per  anum. 

Louis  made  this  the  subject  of  a  Thesis;  for  which  he  was  prosecuted  by  the 
parUament  of  France;  and  the  Doctors  of  the  Sorbonne  interdicted  him  for  ad- 
dressing to  the  causists  the  following  question:  "In  uxore  sic  disposita,  uti  flis 
sit,  vel  non?    judicent  theologi  morales?" 

The  pope,  however,  more  philosophical  than  the  parliament,  or  the  Sorbonne 
Doctors,  gave  absolution  to  Mons.  Louis;  and  his  Thesis  was  published  in  1754. 
— Amilysis  of  the  article  of  "  Extraofdinary  Cases"  in  the  Did.  des  Scien.  Med. 
hy  Mons.  Foumier. 


72  OF  CONCEPTION. 

161.  To  the  third  we  may  say,  it  makes  no  provision  for  the 
formation  of  mules;  for  the  peculiarities  of,  and  likeness  to  pa- 
rents; and  for  the  propagation  of  predisposition  to  disease,  from 
parent  to  child;  for  the  production  of  mulattoes,  &c. 

162.  The  fourth  we  must  leave  to  others  to  object  to — I,  many 
years  since,  promulgated  this  conjecture;  and  it  has  since  been  in 
part  confirmed  by  the  discovery  of  ducts  leading  from  the  ovary 
to  the  vagina,  in  the  cow  and  sow,  by  Dr.  Gartner  of  Copenha- 
gen. I  think  this  is  the  most  simple  mode  nature  could  adopt 
for  the  completion  of  her  favourite  object;  but,  I  confess,  it  wants 
farther  confirmation;  and  this  I  sincerely  hope,  is  reserved  to 
reward  the  industry  of  some  American  searcher  into  the  minute 
anatomy  of  the  human  frame.  I  cannot  but  lament  here  the 
early  death  of  the  indefatigable  and  amiable  Lawrance,  who  had 
intended  tP  have  made  the  search  for  these  vessels  one  of  his 
early  occupations ;  and  from  talents  and  industry  like  his,  what 
might  we  not  have  hoped  for? 

163.  Mod-ern  pathological  researches,  have  lately  added  a  new 
species  of  impregnation  to  those  of  the  uterine,  ventral,  ovarian, 
and  tubal,  to  which  the  name  of  "  Graviditas  in  uteri  substantia, 
or  interstitial  pregnancy,"  has  been  given. 

Sect.  I. — Graviditas  in  Uteri  Substantia,  or  Graviditas  In- 
terstitialis. 

164.  Dr.  Breschet,  an  eminent  physician  of  Paris,  read  a  paper 
on  the  subject  before  the  French  Academy  of  Sciences ;  which 
has  been  reported  on  by  the  celebrated  Geoffroy  St.  Hilaire ;  who 
has  ventured  an  hypothesis  on  the  manner  in  which  this  accident 
occurs,  drawn  from  analogical  observations  made  on  oviparous 
animals.  We  have  no  room  for  the  insertion  of  these  views;  a 
notice  of  which  may  be  seen  in  the  Medico-Chirurgical  Review, 
for  October,  1826.  The  following  is  a  summary,  presented  in 
the  Bibliotheque  Mcdicale;  of  the  cases  hitherto  recorded. 

165.  A  case  published,  in  1801,  by  Schmidt,  in  the  sixth  week 

of  gestation. 
1811,  by  Albers,  at  two  months  and 

a  half. 
1817,  by  Henderich,  at  three  months. 
1821,  by  Henderich,  at  eight  months. 
1823,.  by  Bellemain,  at  three  months. 
1825.  by  Dance,  at  three  months. 


OP  THE  CHANGES  PRODUCED  BY  CONCEPTION.       73 

A  case  published  in  1825,  by  Moulin,  at  two  months  and  a  half. 
1S25,  by  Auvity,  at  one  month. 
166.  Messrs.  Moreau  and  Gardien  report  a  strange  conforma- 
tion of  the  uterus.  "  This  uterus  was  well  made,  with  the  excep- 
tion of  its  having  a  canal  on  the  right  fallopian  tube  enclosed  in 
the  uterine  parietes,  and  opening  in  the  neck  of  this  organ.  This 
vicious  conformation  may  explain  the  cases  which  have  been 
witnessed  of  the  developeraent  of  the  ovum  in  the  uterine  tissue."* 


CHAPTER  VI. 

OF  THE  CHANGES  PRODUCED  BY  CONCEPTION. 

167.  However  philosophers  may  differ,  as  regards  the  mode 
of  application  of  the  male  semen  to  the  female  ovary,  they  all 
agree  that  it  is  either  directly  or  indirectly  essential  to  impreg- 
nation. I  shall  now  consider  the  changes  produced  upon  the 
female  organs  after  this  event  has  taken  place;  and  shall  begin 
with  those  induced  in  the  ovarium.  After  successful  coition, 
an  ovum  is  perceived  to  increase  in  size,  and  is  seen  to  stand  in 
more  decided  relief  than  before  from  the  surface  of  the  ovarium; 
and  it  is  said,  that  this  body  now  becomes  more  vascular.  Ar- 
rangements are  made,  soon  after,  by  the  good  offices  of  the  ab- 
sorbents for  its  liberation  from  its  nidus;  accordingly  it  becomes 
exposed,  by  its  peritoneal  covering  being  destroyed  by  these 
vessels;  and  it  is  now  ready  to  be  embraced  by  the  fimbriated 
extremity  of  a  fallopian  tube,  to  be  conveyed  through  its  cavity, 
to  the  uterus. 

168.  The  tube,  at  this  time,  is  found  in  strict  union  with  the 
ovarium;  and  is,  in  a  short  time  more,  found  possessed  of  this 
little  sphere.  How  it  is  detached  from  its  bed,  is  not  precisely 
understood;  some  say  it  falls  into  the  cavity  of  the  tube — others 
that  it  is  mechanically  forced  into  it,  by  the  firm  grasp  of  the 
tubal  extremity,  &c.:  certain  it  is,  it  rarely  fails  getting  into  this 
canal,  and  made  to  travel  by  some  power  or  other,  its  whole 
length ;  it  is  probably  arrested  at  the  uterine  extremity  for  a  short 

*  Revue  Med.  Vol.  I.  p.  507. 
10 


74  OP  THE  CHANGES  PRODUCED  BY  CONCEPTION. 

time  after  it  arrives  there,  before  it  can  effect  a  lodgment  within 
the  cavity  of  the  womb. 

169.  Physiologists  have  not  settled  the  point  of  time,  at  which 
the  ovum  loses  its  connexion  with  the  ovarium;  nor  the  period 
it  employs  in  travelling  to  the  uterus,  or  when  it  is  admitted 
within  its  walls ;  analogy  has  furnished  almost  the  only  data  that 
even  conjecture  can  rest  upon ;  and,  in  summing  up  the  evidence 
it  affords,  it  would  seem  to  be  about  twenty  days.  A  difficulty, 
however,  has  alwaj^s  presented  itself  to  get  the  ovum  into  the 
cavity  of  the  uterus  after  it  has  arrived  at  the  extremity  of  the 
fallopian  tube.  For  it  would  seem,  from  the  acknowledgments 
of  almost  all  who  have  investigated  this  point  in  the  human  sub- 
ject, that  the  fallopian  tube  is  sealed  by  the  decidua  passing  over 
it;  and  that,  consequently,  the  ovum  must  be  placed  behind  it ; 
the  question  then  is,  how  does  it  overcome  the  difficulty,  that 
this  production  offers  to  its  immediate  entrance  into  the  cavity  of 
the  uterus?  Before  we  attempt  a  solution  of  this  question,  it 
will  be  necessary  to  inquire,  what  this  production  is;  how  it  is 
disposed  of;  and  what  are  its  uses. 

170.  It  would  appear  fi'om  the  observations  of  those,  whose 
opportunities  and  talents  have  led  them  to  the  investigation  of 
this  obscure  part  of  human  physiology,  that  the  following  fact 
constantly  presents  itself;  that,  so  soon  as  impregnation  takes 
place,  and  is  perceived,  if  it  may  be  so  expressed,  by  the  ovarium, 
the  internal  surface  of  the  uterus  throws  out  a  vascular  tissue, 
through  its  whole  extent,  which,  from  its  being  after  a  time  cast 
off,  has  received  the  name  of  membrana  decidua :  this  was  first 
accurately  described  bj^  the  late  Dr.  William  Hunter.  It  is,  I 
believe,  well  ascertained,  that  all  that  is  necessary  to  induce  the 
uterus  to  set  about  secreting  this  coat,  is,  that  a  vesicle  be  im- 
pregnated. And  whether  this  escape  from  the  ovarium  or  not; 
or  tarries  in  the  fallopian  tube;  or  loses  itself  in  the  cavity  of  the 
abdomen,  it  never  fails  to  produce  the  decidua;  and  that  very 
quickly.  Some*  have  thought  it  to  be  a  coagulable  lymph,  which 
soon  became  organized,  by  thousands  of  vessels  shooting  up 
through  the  whole  extent  of  its  surface;  otherst  imagined  it  was 
a  kind  of  continuation  of  the  proper  vessels  of  the  uterus;  and 
Mr.  John  Hunter  believed  it  to  be  originally  a  coagulum  of  blood. 
Injections  prove  it  to  be  highly  vascular;  and  constant  observa- 

*  Dr.  Hunter,  Scarpa,  &c.  t  Haller  and  others. 


OP  THE  CHANGES  PRODUCED  BY  CONCEPTION.        75 

tion  declares  it  to  be  deciduous;  therefore  it  must  be  a  temporary 
product;  and  certainly  subservient  to  the  uses  of  the  embryo. 

171.  It  is  spread  over  the  whole  of  the  internal  surface  of  the 
body  and  fundus  of  the  uterus,  but  does  not  dip  into  its  neck* — 
it  forms  as  it  were  a  bag  within  the  uterus;  sometimes,  we  are 
toldt  it  does  not  stretch  across  the  aperture  formed  by  the  neck ; 
and  sometimes:]:,  it  is  said  not  to  be  continued  over  the  mouths 
of  the  fallopian  tubes.  Mr.  Burns  formerly,  and  Velpeau  more 
recently,  suppose  that  the  decidua  entered  the  mouths  of  the 
fallopian  tubes ;  but  it  must  be  evident  at  first  sight,  that  this 
arrangement  would  only  unnecessarily  obstruct  the  passage  of  the 
ovum  through  these  bodies  to  the  uterus.  See  Essays  on  Vari- 
ous Subjects  connected  with  Midwifery,  by  the  Author,  p.  62. 

172.  The  uses  of  this  new  product  cannot  be  mistaken ;  it 
certainly  serves  as  a  bond  of  union  between  the  ovum  and  the 
uterus;  and  has  moreover  an  indirect  agency  in  the  circulation 
between  the  mother  and  child. 

173.  It  is  described  by  Dr.  Hunter,  Dr.  Hamilton,  Mr.  Burns, 
and  others,  as  a  double  membrane ;  but  as  Mr.  Burns  is  the  latest 
of  these  authors ;  as  he  is  extensively  engaged  in  midwifery ;  and 
has,  as  he  declares,  had  several  opportunities  of  examining  the 
uterus  within  a  month  after  conception ;  and  above  all,  as  he  is 
the  present  authority  for  almost  everything  relative  to  this  subject; 
I  shall  give  his  account  of  the  mode  in  which  the  ovum  places 
itself  behind  the  decidua  that  it  may  finally  descend  into  the 
cavity  of  the  uterus.  He  says,  "  when  the  embryo  passes  down 
through  the  tube,  it  is  stopped,  when  it  reaches  the  uterus,  by  the 
inner  layer  (of  the  decidua)  which  goes  across  the  aperture  of  the 
tube,  and  thus  would  be  prevented  from  falling  into  the  cavity  of 

*  Velpeau  declares  the  contrary  of  this,  by  saying,  it  is  always  found,  *'  in 
the  upper  part  of  the  cervix  in  the  shape  of  solid  concrete  cords,-  and  naturally, 
it  has  no  opening."  We  tlaink  this  account  is  rather  obscui-e;  and  we  are  un- 
certain as  regards  the  real  meaning  of  the  author.  His  expression  is,  (after 
stating  it  sometimes  insinuates  itself  in  the  origin  of  the  fallopian  tubes,)  "  et 
toujoiu's  dans  la  partie  superieure  du  col,  sous  la  forme  de  cordons,  pleins,  et 
concrets."  We  have  used  Dr.  Meigs'  translation  of  these  words,  ("  cordons, 
pleins,  et  concrets,")  because  we  could  not  render  them  differently — yet  we 
are  at  a  loss  for  the  idea  intended  to  be  conveyed,  as  we  have  never  observed, 
any  "solid  concrete  cords"  in  the  many  ova  we  have  examined.  The  neck  of 
the  uterus  is  pretty  constantly  filled  by  a  pretty  dense  coagulum,  which  has 
some  resemblance  to  a  "  cord^"  but  tliis  is  not  the  same  product,  as  the  decidua; 
for,  when  present  in  the  neck,  is  always  below  the  decidua. 

t  Burns,  p.  193.  t  Sii-  E.  Home,  Phil.  Trans 


76  OP  THE  CHANGES  PRODUCED  BY  CONCEPTION. 

the  uterus,  even  were  it  quite  loose  and  unattached.  By  the 
growth  of  the  embryo,  and  the  enlargement  of  the  membranes, 
this  membrane  is  distended  and  made  to  encroach  upon  the  cavity 
of  the  uterus,  or  more  correctly  speaking,  it  grows  with  the  ovum. 
This  distention  or  growth  gradually  increases,  until  at  last  the 
whole  of  the  cavity  of  the  uterus  is  fdled  up,  and  the  protruded 
portion  of  the  m?ier  layer  of  the  decidua  comes  in  contact  with 
that  portion  of  itself  which  remains  attached  to  the  outer  layer. 
We  find,  then,  that  the  inner  layer  is  turned  down  and  covers 
the  chorion;  from  which  circumstances,  it  has  been  called  the 
decidua  reflexa."* 

*  Velpeauf  describes  this  process  differently,  and  we  think  by  no  means  so 
satisfactorily,  bating  the  error  of  Mr.  Bui-ns,  that  the  decidua  is  a  double  mem- 
brane. He  says,  "  the  ovule,  after  passing  through  the  tube,  necessarily  de- 
presses the  caduceous  membrane,  so  that  it  may  glide  on  betwixt  it  and  the  uterus, 
to  the  internal  surface  of  which  it  at  last  attaches  itself;  from  this  moment  the 
pre-existing  membrane  is  composed  of  two  portions;  one  very  large,  lining  the 
whole  interior  of  the  tvomb,  except  the  part  which  is  in  contact  with  tlie  germ, 
bears  the  name  of  uterine  or  external  caduca,-  the  other  very  small,  depressed 
by  tlie  lower  half  of  the  fecundated  vesicle,  which  it  envelopes,  constitutes  the 
reflected  caduca,  internal  caduca,  or  epichorion.  The  extent  of  the  former  aug- 
ments in  the  same  ratio  with  that  of  the  womb,  and  the  aggrandizement  of  tlie 
latter  necessarily  follows  the  youth  of  the  germ."  We  have  three  objections 
principally,  to  this  arrangement.  First,  it  speaks  of  the  ovule  gliding  betwixt 
the  decidua  and  the  uterus — now  tliis  cannot  be — for,  agi'eeably  to  this  scheme, 
whatever  progress  the  "ovule"  may  make  within  the  cavity  of  the  uterus,  can 
only  be  a  mechanical  force  separating  the  decidua  from  the  uterus ;  for  Vel- 
peau  admits,  that  this  membrane  is  very  large,  and  lines  the  whole  cavity  of  the 
utei-us;  consequently,  before  the  o\ade  can  ''glide"  betwixt  it  and  the  uterus,  the 
decidua  must  be  meclianically  detached  from  the  uterine  sui-face — a  work  at  least 
of  supererogation,  if  not  of  violence.  Now,  Mr.  Burns  describes  a  more  simple 
mechanism  for  this  obscm-e  process,  by  supposing  the  ovum  to  carry  along  with 
it,  that  portion  of  the  decidua  that  is  immediately  before  it ;  and  which  increases, 
pari  passu,  with  the  ovule  itself,  and  eventually  becomes  reflected,  by  turn- 
ing down  upon  itself.  Second,  it  makes  the  ovide  attach  itself  to  the  internal 
face  of  the  uterus,  and  this  without  the  intervention  of  the  decidua,  which  can- 
not be — for,  were  tliis  true,  there  would  be  no  necessity  for  this  production, 
since,  agreeably  to  this  plan,  it  does  not  become  the  bond  of  union  between  the 
ovum  and  the  uterus.  Thii-d,  this  accomit  leaves  out  of  view  the  offices  of  the 
choi'ion  for  the  "reflected  caduca,  internal  caduca,  or  epichorion,"  do  not  repre- 
sent tlie  beautiful  protluct  of  this  membrane,  and  which  is  essential  to  the  union 
of  the  ovum  with  the  deciduous  efflorescence,  that  it  may  profit  by  a  connexion 
with  tlie  system  of  the  mother,  but  of  which  no  mention  Is  made.  In  a  word, 
nothing  can  be  more  obsciu'cthan  the  whole  history  of  the  human  ovum  as  given 
by  Velpeau — but  tlus  is  not  the  place  to  point  out  liis  discrepancies. 

t  Elementary  Treatise  of  Midwifery,  tiauslated  by  Dr.  Meigs. 


OF  THE  CHANGES  PRODUCED  BY  CONCEPTION.       77 

174.  From  this  statement  it  would  appear:  1st.  That  the 
decidua  is  a  double  membrane  and  capable  of  separation.  2d. 
That  in  order  that  the  ovum  shall  be  placed  behind  the  inner 
layer,  it  must  pass  through  the  outer  layer;  or,  in  other  words, 
the  outer  layer  must  be  pierced  at  cither  fallopian  tube.  3d.  That 
the  inner  coat  of  the  decidua,  when  pressed  upon  by  the  ovum, 
must  increase  in  proportion  to  the  augmentation  of  that  body, 
that  it  may  come  "  in  contact  ivith  that  j)ortion  of  itself, 
which  remains  attached  to  the  outer  layer,''  or,  in  other  words 
to  become  reflected. 

175.  If  this  arrangement  be  admitted,  it  must  necessarily  fol- 
low, that  the  ovum  will  possess  three  layers  of  decidua  instead 
of  two;  one  more  than  has  ever  been  detected,  or  ever  insisted 
on.  I  have  examined  many  ova,  for  the  purpose  of  understand- 
ing their  mechanism;  and  this  with  all  the  care,  and  all  the  little 
ability  I  have  for  minute  dissection;  and  I  can  most  safely  add, 
without  any  previously  conceived  theory:  yet  I  have  never  been 
able  to  find  but  two  lamina?  of  decidua.  If  Mr.  Burns'  account 
be  true,  where  is,  or  what  becomes  of  the  third  layer.?  and  that 
it  must  have  three  agreeably  to  his  scheme,  is  evident ;  viz.  two 
original  layers,  and  an  acquired  one  by  reflection,  by  the  increase 
of  the  ovum,  as  it  pushes  itself  forward  to  ''  come  in  contact  with 
that  portion  of  itself  which  remains  attached  to  the  outer  layer," 
"  with  which  it  grows." 

176.  It  will  farther  follow  from  these  premises:  (173,  &c.)  L 
That  the  process  in  question,  as  explained  by  Mr.  Burns,  is  not 
exactly  as  he  has  stated  it  to  be ;  or  that,  2.  The  reflected  portion 
must  be  absorbed,  as  quickly  almost  as  formed;  since  it  has  never 
been  observed.  As  regards  ourselves,  we  confess  that  we  have 
but  little  confidence  in  the  history  of  the  ovum  as  given  by  Mr. 
B. ;  and  for  this  plain  and  simple  reason— it  does  not  comport  with 
anatomical  facts;  a  foundation  upon  which  the  whole  must  rest 
to  be  satisfactory. 

177.  I  have  no  faith  in  the  statement,  that  the  decidua  is  a 
double  membrane;  at  least  I  have  never  seen  it  such;  and  of 
course,  until  I  do,  I  shall  admit  it  with  great  caution ;  especially, 
as  it  does  not  appear  necessary  to  the  explanation  of  the  process 
under  consideration.  1st.  Because  a  work  of  supererogation 
would  be  performed  in  making  two  layers,  when  one  appears  to 
be  all  that  is  necessary  ;  and,  2d.  Because,  if  we  believe  it  to  be 
a  single  membrane,  the  explanation  is  easy ;  and  in  entire  confer- 


78  THE  MEMBRANES. 

mity  with  the  anatomy  of  the  ovum,  as  presented  to  us  by  dissec- 
tion. My  opinion  upon  this  subject  then,  is  easily  expressed,  by 
substituting  a  single  membrane  for  a  double  one.  To  understand 
the  union  which  now  takes  place  between  the  ovum  and  this 
adventitious  covering,  it  is  necessary  to  say  a  few  words  on  the 
subject  of 

Sect.  1. —  The  Membranes. 

178.  Reasoning  on  the  subject,  I  was  of  opinion,  that  the  ovum 
brought  its  membranes  with  it  from  the  ovarium  ;  and  I  am  now 
altogether  convinced,  by  the  late  observations  of  Sir  Everard 
Home,  who  detected  them  at  a  very  early  period  of  conception, 
by  the  aid  of  powerful  glasses,  assisted  by  the  skill  of  Mr.  Baur. 
These  membranes  are  two  in  number ;  the  inner  one  is  called  the 
amnion,  and  the  outer  one  the  chorion ;  they  serve  to  enclose  the 
embryon  and  the  water  in  which  it  floats,  even  while  it  sojourns 
in  the  ovarium.  After  the  escape  of  the  ovum  from  thence,  these 
membranes  serve  two  other  important  ends;  one  is,  to  furnish  by 
means  of  the  amnion  a  quantity  of  fluid  for  the  protection  of  the 
very  tender  molecule  within  ;  and  the  other,  by  changes  which 
take  place  in  the  surface  of  the  chorion^  to  connect  it  with  the  in- 
ternal face  of  the  uterus, 

179.  At  first  these  membranes  are  not  in  immediate  contact 
with  each  other  f  having  between  them  a  jelly-like  substance, 
which  fills  up  the  space  that  separates  them  ;  after  awhile,  how- 
ever, owing  to  the  increase  of  growth  of  the  amnion,  and  a  dimi- 
nution of  the  gluten,  they  approximate  each  other  so  nearly,  that 
they  may  be  said  to  touch.  The  amnion  is  thin,  transparent, 
smooth,  and  destitute  of  vessels,  discoverable  by  the  eye ;  it  lines 
or  lies  below  the  chorion;  spreads  itself  over  the  placenta ;  and 
invests  the  umbilical  cord  to  the  umbilicus — here  it  stops. 

180.  The  chorion  is  also  a  thin,  pretty' transparent  membrane; 
and  is,  at  the  full  period  of  gestation,  oftentimes  sufficiently 
strong,  to  resist  for  a  long  time  the  impulses  of  labour.  The 
precise  anatomical  structure  of  this  membrane,  is  not  perhaps  al- 

*  This  circumstance,  though  admitted  by  almost  all  the  writers  on  this  subject, 
and  confessedly  curious,  and  almost  necessarily  important,  has  never,  so  far  as 
we  recollect,  elicited  a  conjecture  as  to  the  probable  intention  of  this  arrange- 
ment. Is  it  to  protect  the  feeble  and  delicate  germ  from  impulse  or  shock,  at 
this  early  and  tender  period  of  its  existence  ? 


THE  MEMBRANES.  79 

together  well  understood  at  this  moment — therefore  much  has 
been  left  to  conjecture,  as  regards  its  more  intimate  composition. 
Some  have  assigned  lymphatics,  nerves,  lymphatic  exhalents, 
and  inhalents,  but  we  believe  withgut  sufficient  authority.  Indeed, 
it  would  seem  that  Velpeau*  calls  in  question  the  existence,  of  the 
lymphatic  exhalents  and  inhalents  altogether,  in  the  composition 
of  any  part  of  the  animal  structure ;  which,  if  admitted,  would 
very  much  embarrass  the  doctrines  of  the  physiological  school, 
whether  the  human  body  be  viewed  in  a  normal  or  pathological 
condition.  He  says  ''  these  two  last  mentioned  kind  of  vessels 
having  been  admitted  in  animal  bodies,  upon  the  say-so  of  the 
physiologists,  especially  Bichat,  who  never  saw  them,  it  is  good 
philosophy  to  reject  their  existence  without  discussion,  until  they 
shall  have  been  demonstrated  by  more  conclusive  proofs.  The 
same  may  be  said  of  the  lymphatics,  which  the  imagination  of 
Schrsegar  and  some  others,  seems  to  me  to  have  detected  on  the 
chorion.  As  to  nerves,  I  think  I  may  say  without  offence  to 
Chaussier,  MM.  Ribes,  Home  and  Baur,  that  they  are  no  more  to 
be  found  there,  than  the  exhalents,  and  lymphatics."  We  think, 
however,  that  this  is  rather  a  hasty,  and  uncandid  denunciation; 
at  least,  as  regards  the  exhalents,  and  perhaps  the  lymphatics ;  as 
a  useful  purpose  might  be  assigned  for  their  existence,  if  we  cannot 
imagine  any  utility  in  the  presence  of  nerves  in  so  insulated  a 
membrane.  It  adheres  very  firmly  to  the  placenta,  and  gives  a 
covering  to  all  its  superficial  vessels;  it  also  accompanies  the 
amnion,  along  the  whole  extent  of  the  cord.  Its  outer  surface, 
very  quickly  after  its  escape  from  the  ovarium,  is  found  to 
assume  a  cellular  appearance,  and  soon  after  a  flocculent  one — 
it  is  this  coat  which  furnishes  from  its  external  surface,  the  innu- 
merable vessels  by  which  it  unites  itself  to  the  uterus  by  means 
of  the  decidua.  When  this  union  is  effected,  an  interchange  of 
offices  takes  place  between  the  chorion  and  decidua;  they  recip- 
rocally permit  each  other's  vessels  to  repose  themselves  through- 
out their  respective  extents,  by  interlocking  in  such  manner,  as  to 
establish  a  firm  union  between  them.  The  extremities  of  the 
vessels  of  the  chorion,  penetrate  the  interstices  offered  by  the 
vessels  of  the  decidua;  while  those  of  the  latter,  seek  refuge  in 
the  meshes  of  the  chorion.!     The  union  of  the  chorion  with  the 

•  Dr.  Meigs'  Translation,  p.  159. 

t  Velpeau  denies  the  vascularity  of  these  filamentous  productions— we  are 
far  from  being  satisfied  that  he  is  correct  in  making  this  denial.  If  we  compre- 


80  THE  MEMBRANES. 

dccidua  is  so  strict,  especially  after  the  second  month,  as  always 
to  bring  it  with  it,  in  cases  of  abortion. 

181.  These  membranes  enclose,  besides  the  embryo  and  pla- 
centa, a  fluid  called  the  liquor  amnii — it  would  seem  to  be  the 
product  of  the  amnion  ;  in  this  the  foetus  securely  floats  from  its 
earliest  existence,  until  the  last  period  of  utero-gestation.  It 
seems  to  be  but  little  more  than  water;  having  but  a  little  gluten, 
and  muriate  of  soda  in  it.  It  is  sometimes  transparent  like  water  ; 
at  other  times  it  is  yellow,  brown,  green,  &c.  and  of  various 
consistencies.  Sometimes  it  is  much  more  abundant  than  at 
others;  from  four  ounces,  to  as  many  pints.  The  use  of  this 
fluid  is  to  give  a  uniform  distention  to  the  uterus — to  protect  the 
foetus  against  external  injuries;  and  to  afibrd  it  the  most  gentle 
and  secure  medium  to  repose  in.  Dr.  Denman*  says,  it  also 
"procures  the  most  gentle,  yet  efficacious  dilatation  of  the  os 
uteri,  and  soft  parts  at  the  time  of  parturition."  This  opinion  I 
shall  have  occasion  to  advert  to.t 

182.  The  ovum,  after  its  establishment  within  the  uterus,  or 
after  it  is  expelled  by  violence  from  it,  consists  of  the  decidua, 
the  decidua  reflexa,  chorion,  and  amnion;  of  the  liquor  amnii, 
the  foetus,  and  umbilical  cord — the  latter  has  one  extremity  in- 
serted into  the  umbilicus  of  the  child;  the  other  affixed  to  the 
membranes,  which  now  constitute 

hend  this  author,  the  formation  of  the  placenta  is  entirely  independent  of  the 
decidua  and  chorion — a  circumstance,  to  say  the  least,  that  wants  proof.  He 
says,  **it  is  generally  thought  that  the  down  that  covers  the  chorion  is  of  a  vas- 
cular nature;  but  as  early  as  1823, 1  ventured  to  oppose  this  hypothesis.  What 
proves  that  the  filaments  of  the  chorion  are  not  vessels,  is  this,  that  thc^^  are  to 
be  seen  before  the  blood-vessels  of  the  cord  are  recognizable.  Besides,  until  the 
sixth  week,  every  Jlock  {fiUment)  is  at  least  as  large  as  one  of  the  umbilical  ves- 
sels; so  that,  as  there  are  only  tlu-ec  of  these,  it  is  difficult  for  them  to  give  birth 
to  the  others,  which  amount  to  several  hundred.  Fiu-ther,  tliese  vilosities  are 
regularly  spread  over  the  whole  of  tlie  periphery  of  the  ovule,  and  are  indepen- 
dent of  each  other,  while  the  cord  and  placenta  are  only  connected  with  one 
point  of  this  vesicle."  M.  Velpeau  seems  to  forget  that  this  kind  of  arrange- 
ment exists  in  the  fully  developed  placenta — for  the  cord  is  inserted  but  atone 
point  of  this  mass;  and  it  would  puzzle  him  to  show  that  the  whole  composition  of 
this  important  organ,  is  not  vascular;  and  that  the  area  of  all  this  immense  conge- 
ries of  vessels,  does  not  exceed  tlie  area  of  the  vessels  constituting  the  cord. 

•  Introduction,  Francis's  ed.  p.  219. 

t  See  what  is  said,  when  we  speak  of  the  opening  of  the  os  uteri. 


THE  PLACENTA.  81 

Sect.  II. — The  Placenta. 

183.  The  placenta  is  that  vascular  mass,  by  which  the  circu- 
lation is  maintained  between  mother  and  child ;  and  by  which 
the  latter  is  nourished.  Its  size  is  various,  owing  to  the  consti- 
tution of  either  mother  or  child,  or  both — it  resembles  in  shape 
a  large  cake;  it  is  in  general  nearly  circular,  thicker  in  the  mid- 
dle than  at  the  edges.  It  presents  two  surfaces ;  namely  the 
uterine  or  maternal  surface;  and  the  foetal  surface.  The  former 
presents  rather  a  rough  and  spongy  appearance,  traversed  by 
several  sulci  of  very  inconsiderable  depth;  it  is  not  unaptly 
compared  in  its  appearance  to  the  infractuosities  of  the  brain ;  it 
is  covered  by  a  very  fine  cellular  coat,  but  of  such  great  delicacy, 
as  to  break  upon  the  slightest  bending  of  this  mass.  The 
eminences  and  sulci  observed  upon  its  maternal  face,  have 
been  supposed  to  arise  from  a  kind  of  necessity,  for  the  greater 
security  of  attachment,  by  corresponding  risings  and  sinkings, 
on  the  internal  face  of  the  uterus.  I  do  not  believe  in  this  ne- 
cessity, and  suppose  these  sulci  are  the  mere  impressions  of  the 
maternal  vessels,  which  are  so  much  swelled  beyond  the  plane 
of  the  common  surface  of  the  uterus,  as  to  impress  the  placenta 
with  furrows  like  the  internal  surface  of  the  skull,  by  the  ves- 
sels of  the  encephalon. 

184.  The  internal  surface  is  covered  by  the  chorion  and  am- 
nion, through  whose  coats  may  be  perceived  a  beautiful  display 
of  vessels;  sometimes  they  are  found  in  fine  regular  order,  like 
radii  from  a  centre;  at  others  running  into  fantastic  irregularity; 
these  vessels  are  both  the  arteries  and  veins,  which  tend  to  a 
common  point,  and  when  united  form  what  is  called  the  umbilical 
cord:  in  uniting  to  form  this  rope,  they  sometimes  run  parallel 
to  each  other  for  several  inches;  then  twine  round  each  other  al- 
ternately until  they  arrive  at  the  umbilicus  of  the  child.*     They 

*  ■  Velpeau  makes  the  twisted  appearance  of  the  cord  to  depend  upon  the 
movements  of  the  fcetus;  he  says,  "  the  reason  of  this  twisted  appearance,  seems 
to  me  to  be  very  plain :  it  depends  on  the  rotatory  movements  of  the  cliild  in 
the  womb,  and  ten  times  out  of  twelve,  it  turns  from  left  to  right,  according  to 
my  own  and  Meckel's  observation.  In  some  subjects  the  cm-d  is  turned  in  one 
direction  near  the  placenta,  and  in  the  opposite  one  near  the  child's  belly,-  most 
frequently  it  looks  like  a  real  rope,  and  hence,  doubtless,  is  derived  its  name, 
Cord.  Sometimes  all  1;hree  of  the  vessels  turn  on  an  ideal  axis  ;  at  others  the 
vein  is  twisted  round  the  arteries,  but  in  general,  the  arteries  are  twisted  round 
the  vein,"  p.  77.  It  is  truly  surprising  that  M.  Velpeau  should  have  offered 
11 


82  THE  PLACENTA. 

are  connected  through  then-  whole  extent  by  a  fine  cellular  pro- 
duct, in  the  interstices  of  which,  we  constantly  find  a  tenacious, 
ropy  fluid. 

185.  This  cord  consists  almost  always  of  two  arteries  and  a 
vein:  the  vein  conveying  the  blood  to  the  foetus,  and  the  arteries 
conducting  it  from  it;  the  veins  of  the  placenta  rarely  have 
valves ;  while  valves  are  frequently  found  in  the  arteries.  The 
arteries  are  continuations  of  the  iliacs  of  the  foetus;  they  pass  out 

such  an  unphilosophical  explanation  of  the  disposition  of  the  umbilical  vessels; 
especially  as  he  is  so  sceptical  upon  certain  physiological  points,  that  are  every 
wa)'  vastly  more  probable  than  the  one  in  question — for  instance,  his  doubts 
of  the  existence  of  serous  or  lymphatic  vessels  in  the  chorion  ;  lymphatics  them- 
selves ;  blood-vessels  as  belonging  to  the  same  membrane;  the  vascular  natvire 
of  the  spongy  chorion,  &c.  &c.  Now,  as  regards  tlie  cause  of  the  twist  in  the 
umbilical  vessels,  lais  explanation  is,  we  had  hke  to  have  said,  absurd,  and  he 
himself  furnishes  arguments  enough  to  destroy  it,  without  our  havingthe  trouble 
to  furnish  more.  For  instance — he  says,  that  "the  cord  in  some  subjects  is 
turned  in  one  du-ection  near  the  belly  of  the  cliild,  and  in  another,  near  the 
placenta."  Now  a  school-boy  would  laugh  at  any  one,  were  he  directed  to  twist 
his  whip  cord  in  one  dii-ection  at  one  end,  and  in  the  opposite  direction  at  the 
other,  without  some  intervening  reraora ;  for  the  little  rogue  would  know,  that 
these  contrary  efforts  to  twist  his  string,  would  instantly  destroy  each  otlier. 
Again ;  if  tlie  fact  be  admitted,  that  the  cord  is  twisted  by  the  gyrations  of  the 
child,  why  does  not  the  twist  unfold  itself  when  one  of  its  extremities  is  set  at 
perfect  libei'ty  by  cutting  tlic  funis  ? — Did  M.  Velpeau,  or  any  body  else,  ever 
see  the  umbilical  cord  twirl  itself  in  an  opposite  direction  to  the  twist,  upon  be- 
coming detached  from  the  child  or  placenta  ?  Again;  were  this  the  ti'ue  ex- 
planation, why  is  the  twist  confined  to  the  vessels  constituting  the  cord,  and  the 
membranes  covering  them,  not  implicated  by  the  same  mechanical  movements  ? 
Why  are  the  membranous  parts  of  the  cord,  without  the  slightest  twist,  when 
the  vessels  run  parallel  to  each  other,  for  some  distance,  nay  in  some  instances, 
for  several  inches  together,  wliile  in  the  portions  both  above  and  below,  the 
vessels  shall  surround  each  othei-,  as  in  ordinary  ?  Does  not  the  fixct  detailed 
by  M.  V.  himself,  seem  to  prove,  that  God  has  established  some  law,  and  for  some 
wise  purpose,  upon  this  subject?  or  why  should  the  direction  of  the  vessels  be 
"ten  times  out  of  twelve,  from  left  to  i-ight?"  Were  the  spiral  directions  of 
the  vessels  of  the  cord  contingent,  why  should  they  not  be  in  equal,  or  nearly 
in  equal,  proportion  to  each  other?  Why  should  they  "be  ten  times  out  of 
twelve,  from  left  to  right?  Can  M.  V.  give  us  any  explanation  of  the  law  that 
governs  the  motion  ofthe  child  in  this  case,  and  which  obliges  it  to  gj-rate  from 
right  to  left,  that  it  may  twist  the  cord  from  left  to  right?  &c.  See.  Again ;  Mr. 
V.  informs  us  immediately  after,  that  it  would  be  a  mistake  to  suppose  that 
the  umbilical  vessels  never  separate,  because  they  do  not  generally  do  so. 
"Theu"  di^asion  may  take  place  at  the  distance  of  one,  two,  or  four  inches  from 
the  inner  surface  of  the  chorion,  and  even  very  near  the  abdomen  of  the  child." 
In  such  cases,  what  has  become  ofthe  gyrating  influence  of  the  child — for  had 
this  existed,  these  are  the  very  parts  that  would  have  first  felt  its  effects. 


FffiTAL  CIRCULATION.  83 

at  the  umbilicus,  and  run  to  lose  themselves  in  the  substance  of 
the  placenta:  they  anastomose  with  each  other  within  the  meshes 
of  this  mass,  as  well  as  with  some  of  the  venal  branches;  this 
kind  of  communication  is  sufficiently  extensive,  to  enable  us  to 
fill  the  whole  plexus,  by  injecting  one  of  the  umbilical  arteries; 
in  like  manner  may  the  arteries  be  filled  by  injecting  the  vein. 
The  vein  originates  by  many  branches  in  the  substance  of  the 
placenta,  and  after  a  variety  of  unions,  collects  itself  into  one 
trunk,  near  where  the  arteries  give  off  branches,  the  area  of 
which  is  rather  more  than  that  of  the  two  arteries. 

186.  This  mass  is  subject  to  various  afi'ections,  some  of  which, 
as  sub-inflammation,  dropsical  infiltrations,  and  ossification,  ap- 
pear to  be  destructive  to  the  foetus;  while  others,  as  varicose 
affections  of  its  superficial  veins,  and  ossification  of  portions  of 
its  reticulated  substance,  do  not  appear  to  have  any  influence 
upon  its  health.  Dr.  Katerbau  states,  that  "in  the  month  of 
February,  1828,  a  woman  was  delivered  of  a  healthy  female 
child;  she  had  complained,  many  weeks  previous  to  her  confine- 
ment, of  a  pain  in  the  womb,  and  a  feeling  as  if  something  within 
it  pricked  and  cut  her;  for  these  sensations  many  remedies  were 
administered  without  effect.  After  a  tolerable  speedy  birth  of 
the  child,  the  placenta  did  not  come  away,  and  the  midwife  sup- 
posing it  to  adhere,  proceeded  to  loosen  it,  which  was  easily 
done.  During  the  operation  the  patient  complained  of  violent 
pricking  within  the  uterus." 

187.  "Upon  inspecting  the  placenta,"  the  Doctor  remarks, 
I  found,  tliroughout  its  substance,  that  "numerous  spicula  of  bone 
were  interspersed,  the  whole  of  which  resembled  the  points  of 
ossification  in  a  foetal  skull;  they  were  firmly  united  to  the  inte- 
guments of  the  placenta,  and  in  some  parts,  especially  over  the 
insertion  of  the  cord,  were  arranged  together  so  as  to  present 
somewhat  of  an  arborescent  appearance."* 

188.  We  have  seen  a  number  of  instances  of  similar  partial 
ossifications  of  the  placenta,  but  in  none  of  which,  did  we  per- 
ceive that  this  condition  interfered  with  its  usual  economy. 

Sect.  III. — FceUiI  Circulation. 

189.  There  are  five  striking  peculiarities  in  the  sanguiferous 
system  of  the  fretus:   1st.  The  vena  umbilicalis.     2d.  The  ductus 

*  Hufeland  and  Osann's  Journal,  June,  1828. 


84  FffiTAL  CIRCULATION. 

venosus.     3d.  The  foramen  ovale.     4th.  The  ductus  arteriosus. 
5th.  The  arterise  umbilicales. 

190.  1,  The  vena  umbilicalis  arises  by  very  fine  branches  in 
the  placenta.  These  branches  are  collected  into  one  trunk,  near 
the  centre  of  the  placenta;  which  trunk,  forming  a  considerable 
part  of  the  volume  of  the  cord,  enters  the  abdomen  through  the 
navel,  and,  running  along  the  anterior  margin  of  the  suspensory 
ligament  of  the  liver,  empties  into  the  left  branch  of  the  sinus  of 
the  vena  portarum.  While  it  is  engaged  in  the  anterior  section  of 
the  umbilical  fissure  of  the  liver,  it  gives  off  several  small  branches 
to  the  substance  of  the  liver.  Nearly  two-thirds  of  its  blood  is 
distributed  to  the  liver,  through  the  sinus  of  the  vena  portarum 
and  the  small  branches. 

191.  2.  The  ductus  venosus  arises  from  the  left  branch  of  the 
sinus  of  the  vena  portarum,  and  empties  into  the  left  hepatic  vein, 
near  the  junction  of  the  latter  with  the  ascending  vena  cava  ab- 
dominalis.  The  ductus  venosus  occupies  the  posterior  section  of 
the  umbilical  fissure,  being  much  smaller  than  the  vena  umbili- 
calis, and  arising  from  the  sinus  of  the  vena  portarum,  at  its  back 
part,  directly  in  face  of  the  entrance  of  the  umbilical  vein,  so  that 
a  probe  may  be  passed  very  readily  from  the  one  into  the  other. 

192.  3.  The  foramen  ovale  is  a  large  aperture  between  the  two 
auricles  of  the  heart,  furnished  with  a  valve  on  its  left  side,  which 
is  shut  down  the  moment  after  respiration  begins. 

193.  4.  The  ductus  arteriosus  is  a  canal  leading  from  the  pul- 
monary artery  into  the  aorta.  It  is  so  large  as  to  appear  like  a 
continuation  of  the  pulmonary  artery,  and  discharges  into  the 
aorta  at  the  lower  part  of  its  curvature,  just  after  the  origin  of 
the  left  subclavian  artery.  The  right  and  left  pulmonary  arte- 
ries, being  at  this  time  but  very  small  branches,  arise  on  each 
side  of  the  ductus  arteriosus. 

194.  5.  The  arterise  umbilicales  are  two  in  number,  being 
continuations  of  the  internal  iliac  arteries,  which  are  here  much 
larger  than  the  external  iliacs.  The  arteriae  umbilicales  make  a 
curve,  running  on  the  lateral  parietes  of  the  bladder,  converge  to 
the  navel,  and,  passing  through  it,  accompany  the  umbilical  vein 
to  the  placenta.  They  twist  spirally  around  it,  and  are  distri- 
buted by  very  fine  branches  to  the  placenta,  communicating 
with  the  extreme  branches  of  the  umbilical  vein. 

195.  The  course  of  the  foetal  circulation  is  then,  from  the  pla- 


OP  THE  CHANGES  WHICH  TAKE  PLACE,  &C.  85 

centa  through  the  umbilical  vein  and  ductus  venosus,  into  the 
ascending  cava,  whereby  the  blood  is  discharged  into  the  right 
auricle  of  the  heart.  The  position  of  the  eustachian  valve  is 
such  as  to  turn  the  greater  part  of  this  column  of  blood  into  the 
left  auricle  through  the  foramen  ovale.  The  left  auricle  may, 
therefore,  be  considered  as  distended  with  the  blood  of  the  as- 
cending cava,  while  the  right  auricle  is  distended  with  the  blood 
of  the  descending  cava.  The  auricles  contract  at  the  same  time, 
and  fill  the  ventricles.  The  ventricles  also  contract  together, 
and  fdl  the  pulmonary  artery  and  the  aorta.  .  The  size  of  the 
ductus  arteriosus  enables  the  right  ventricle  to  discharge  the 
greater  part  of  its  blood  through  it  into  the  descending  aorta. 
This  blood  is  very  impure.  The  blood  passing  through  the  fora- 
men ovale  to  the  left  side  of  the  heart,  by  being  driven  through 
the  root  of  the  aorta,  is  turned  off  to  the  head  and  upper  extre- 
mities, through  the  arteria  innominata,  the  left  carotid  and  left 
subclavian;  and  what  remains  after  this  diversion,  joins  the  blood 
of  the  ductus  arteriosus  in  the  descending  aorta.  A  small  portion 
of  the  blood  of  the  descending  aorta  goes  to  the  lower  extremi- 
ties, and  hy  much  the  greater  part  circulates  through  the  um- 
bilical arteries  to  the  placenta,  where,  after  being  vivified,  it 
runs  into  the  extreme  branches  of  the  umbilical  vein,  d^nd  then 
repeats  the  same  round  until  respiration  begins.*  For  the  most 
part,  immediately  on  respiration  occurring,  the  vena  umbilicalis, 
the  ductus  venosus,  the  foramen  ovale,  the  ductus  arteriosus,  and 
the  arteriae  umbilicales,  are  closed,  not  to  be  again  opened  unless 
in  very  extraordinary  cases. 

Sect.  IV.— Q/'  the  Changes  which  take  place  in  the  Uterus 
fro7n  Impregnation. 
196.  Hitherto  I  have  been  considering  the  changes  induced 
upon  the  ovum  by  impregnation;  it  is  now  proper  to  notice 
those  which  take  place  in  the  parietes  of  the  uterus  itself  These 
changes  commence  on  the  internal  surface  of  the  uterus  with 

*  Dr.  Ryan,  in  his  "Manual  of  Midwifery,"  p.  142,  says,  "  Dr.  Devvees  is  con- 
fused on  this  point,  for  he  alleges  that  the  blood  discharged  by  tiie  umbilical  ar- 
teries passes  into  the  umbilical  vein,  and  is  there  purified ;  which  cannot  happen." 
Dr.  R.  has  certainly  read  the  passage  marked  by  italics,  without  due  attention— 
the  reader  will  please  to  compare  the  above  quotation  with  what  I  have  really 
said. 


86  OP  THE  CHANGES  WHICH  TAKE  PLACE 

those  on  the  surface  of  the  ovum ;  for  no  sooner  is  a  vesicle  fe- 
cundated, than  the  uterus  has  more  than  its  usual  quantum  of 
blood  sent  to  it;  and  this  increases  with  the  progress  of  gestation. 
The  vessels,  as  already  noticed,  are  very  small,  and  very  much 
convoluted  before  fecundation;  now  quickly  enlarge,  and  become 
straighter — and  this  increase  and  developement  continues  until 
they  arrive  at  a  very  considerable  magnitude;  so  much  so  indeed, 
that  some  of  the  largest  of  these  vessels,  at  the  full  period  of 
utero-gestation,  are  capable  of  admitting  the  extremity  of  the 
little  finger. 

197.  The  fibres  of  which  the  uterus  is  chiefly  composed,  begin 
to  develope  themselves,  so  as  to  be  recognized,  as  muscular — 
they  assume  more  distinct  directions,  and,  though  not  susceptible 
perhaps  of  positive  demonstration  as  to  course,  and  form,  are 
yet  sufficientl}^  palpable  to  deserve  the  name  of  muscular  fibres. 
In  consequence  of  this  change,  these  fibres  become  longer  and 
more  lax;  and  admit  without  restraint,  the  interposing  and  much 
enlarged  vessels  that  traverse  them  in  all  directions,  until  the 
uterus  itself  is  no  longer  capable  of  bearing  further  distention  with 
safety. 

198.  This  increase  of  size  is  by  no  means  without  its  laws — 
on  the  contrary,  the  most  perfect  regularity  and  order  are  main- 
tained, from  the  beginning  to  the  end  of  gestation — so  uniform  is 
the  progress  of  developement,  that  the  period  of  pregnancy  can 
with  considerable  certainty  be  pointed  out  by  the  experienced 
accoucheur,  by  ascertaining  the  degree  of  distention  the  uterus 
has  undergone,  provided  it  be  beyond  the  third  month.  Until 
this  time,  we  are  of  opinion,  that  it  would  be  hardly  safe  to 
hazard  a  positive  opinion,  especially  in  such  cases  in  which  it 
may  be  highly  important  to  decide;  and  in  which  a  decision  may 
involve  both  life  and  character. 

199.  The  position,  as  well  as  distention  of  the  uterus,  lead  us 
to  a  knowledge  of  the  advancement  of  pregnancy — for  the  first 
three,  and  sometimes  at  the  fourth  month,  the  uterus  is  found,  in 
consequence  of  its  weight,  rather  lower  in  the  vagina  than  it 
usually  is  when  not  impregnated — after  the  fourth  month,  or  at 
the  end  of  the  fifth,  the  fundus  can  be  felt  at  the  pubic  region — 
at  the  sixth,  half  way  between  it  and  the  umbilicus — at  the 
seventh,  at  the  umbilicus — at  the  eighth  half  way  between  the 
umbilicus  and  the  scrobiculus  cordis — at  the  ninth,  but  very 
little  higher,  in  a  well-formed  pelvis.     For,  at  this  time,  there  is 


IN  THE  UTERUS  PROM  IMPREGNATION.  87 

a  subsiding  of  the  uterus  -vvithin  the  pelvis,  owing  to  the  more 
frequently  repeated,  and  stronger  contractions  of  the  body  and 
fundus,  and  the  now  almost  complete  developement  of  the  neck 
of  the  uterus.  It  is  not,  however,  the  fundus  and  body  alone, 
that  suffer  changes  during  the  periods  just  stated;  the  neck,  after 
the  sixth  month,  participates  in  these  alterations — it  gradually 
becomes  shorter  and  shorter,  until  after  the  eighth  month;  and, 
at  the  ninth  it  is  entirely  obliterated. 

200.  The  body  and  fundus  first  yield  to  the  influence  of  the 
ovum;  and  they  continue  to  expand  until  about  the  seventh 
month,  or  perhaps  a  little  earlier — after  this  time,  they  seem  to 
refuse  to  yield  farther;  the  neck  then  is  obliged  to  contribute 
its  mite  for  the  farther  accommodation  of  the  foetus,  and  its  ap- 
purtenances, which  it  does  until  the  period  of  labour  com- 
mences— at  this  time,  no  trace  of  the  neck  is  to  be  found — no- 
thing remains  of  this  pendulous  part,  but  its  orifice;  which  now, 
may  be  distinctly  observed  to  be  a  little  open. 

201.  The  fundus  and  body  of  the  uterus,  not  only  yield  before 
the  neck,  but  some  one  part  contributes  more  than  another  to 
the  room  necessary  for  the  comfort  of  the  foetus ;  and  these  are 
the  posterior  portions — hence  they  are  found  thicker,  in  the 
unimpregnated  state;  (121)  and  hence,  the  fallopian  tubes  are 
always  found  at  the  last  period  of  pregnancy,  in  advance  of  the 
uterus — a  fact  of  much  importance  in  performing  the  Coesarean 
section. 

202.  In  proportion  to  the  advancement  of  pregnancy,  the 
uterus  acquires  a  deeper  tone  of  colour — this  is  owing  solely  to 
the  augmented  quantity  of  blood  which  it  now  possesses. 

203.  The  power,  by  which  the  uterus  is  distended,  has  been 
disputed.  Dr.  Denman  will  not  admit  the  agency  of  the  ovum; 
he  says,  "it  is  evidently  not  mechanical  from  the  increasing  size 
of  the  ovum,  but  from  the  accession  of  a  new  principle ;  for  the 
uterus  is  never  fully  upon  the  stretch,  like  a  bladder  inflated 
with  air,  but  relaxed  in  such  a  manner  as  to  be  apparently  capa- 
ble of  bearing  the  farther  increase  of  the  ovum  without  incon- 
venience." 

204.  We  should  be  at  a  loss  to  comprehend  this  doctrine  of 
Dr.  Denman's  were  we  even  to  admit  his  proof — to  say  the  ute- 
rus has  acquired  a  new  principle,  does  not  do  away  the  difficulty 
of  understanding  how  it  acquires  size,  unless  something  be  posi- 
tively added  to  this  organ,  at  the  time  it  gains  the  principle — for 


88 

he  must  admit  the  uterus  is  enlarged ;  yet  it  is  not  distended 
like  a  bladder  filled  with  air! — In  what  does  the  difference  con- 
sist? There  must  be  an  increase  of  matter,  as  well  as  "an  ac- 
cession of  a  new  principle,"  to  prevent  its  being  distended  like 
"a  bladder  filled  with  air,"  or  it  must  be  stretched  like  one. — 
If  it  be  declared  there  is  an  increase  of  matter,  we  would  ask 
for  the  evidence;  as  well  as  inquire  what  becomes  of  it,  immedi- 
ately after  delivery?* 

205.  I  am  of  opinion  that  were  the  bladder  circumstanced 
precisely  like  the  uterus,  or  the  uterus  like  the  bladder,  the 
same  phenomena  would  present  themselves — that  is,  let  the  ute- 
rus be  deprived  of  its  adventitious  blood,  as  would  happen  after 
severe  hsemorrhage,  and  it  would  be  found  as  thin  nearly,  or  per- 
haps quite,  as  the  bladder,  all  things  being  equal — or  let  the  mus- 
cular fibres  of  the  bladder  be  separated  by  as  many,  and  as  large 
vessels  as  those  of  the  uterus,  and  it  would  be  as  thick  as  the 
uterus  when  in  a  state  of  distention;  for  we  must  deny  that  the 
uterine  parietes,  when  freed  from  all  their  blood,  are  as  thick  as 
they  were  when  unimpregnated. 

206.  Dr.  Denman  denies  that  the  uterus  ever  is  in  a  state  of 
"full  distention;"  I  do  not  know  what  he  would  wish  us  to  un- 
derstand by  "full  distention;"  if  he  mean,  that  it  is  still  capable, 
under  extreme  pressure,  of  yielding  farther,  I  should  agree  with 
him,  that  it  is  still  capable  of  greater  distention:  but  if  he  mean, 
that  it  is  never  as  much  distended,  as  is  compatible  with  either 
its  economy  or  comfort,  at  the  full  period  of  utero-gestation,  I 
would  certainly  deny,  and  would  seek  for  no  other  proof,  than 
the  well  known  fact,  that  after  the  seventh  month,  it  is  constantly 
found  resisting  further  encroachments,  by  being  excited  to  regu- 

*  I  am  happy  to  avail  myself  of  the  opinion  of  the  judicious  and  experienced 
Dr.  llamsbotham,  upon  this  subject.  He  says,  "that  there  is  no  actual  deposi- 
tion of  new  animal  matter  within  the  uterine  structure  diu'ing  pregnancy,  ap- 
pears to  me  evident  in  the  estabhshed  fact,  that  the  uterus,  by  a  process  of  silent 
and  gradual  contraction,  continued  for  some  time  after  the  expidsion  of  its  con- 
tents, can  and  does  possess  the  power  of  daily  diminishing'  its  volume,  until  it 
has  acquired  its  smallest  unimpregnated  size;  when  it  is  again  able  to  resume 
its  original  and  peculiar  functions.  But  if  the  parietes  of  the  gravid  uterus  be 
supposed  to  owe  their  size  to  bulk,  acquired  by  the  deposition  of  new  animal 
matter,  by  what  natural  means  is  that  matter  so  suddenly  removed?  Can  the 
effects  of  absorption  be  thought  equal  to  it  ?  We  see  no  such  rapid  diminution 
of  size  from  the  powers  of  the  absorbent  system  under  diseased  structure.  Con- 
traction alone  explains  it." — Pract.  Obs.  Jm.  ed.  p.  26. 


OP  THE  DEVELOPEMENT  OP  THE  PCETUS.  89 

lar,  and  constant  contractions,  as  may  be  distinctly  perceived  by 
the  introduction  of  the  finger  into  the  os  uteri.  Besides,  did  we 
not  admit  this  resistance  to  farther  distention  on  the  part  of  the 
body  and  fundus,  how  shall  we  ever  explain  the  unfolding  of  the 
neck  of  the  uterus  at  the  period  just  indicated?  Now,  if  it  be 
distended  at  the  ultimate  period  of  pregnancy,  to  the  point  of 
resistance,  would  it  not  seem  to  be  a  rational  and  natural  deduc- 
tion, that  it  had  proceeded  to  "  full  distention,"  or  at  least,  as  far 
as  was  compatible  with  its  economy,  or  even  with  the  integrity 
of  its  organization? 

207.  We  may  also  urge  in  favour  of  the  ovum  having  an  agency 
by  its  growth  in  the  distention  of  the  uterus,  that,  if  the  liquor 
amnii  be  discharged,  the  uterus  will  collapse  immediately,  and 
accommodate  its  parietes  to  the  form  and  size  of  the  remaining 
contents.  Could  this  be,  did  the  uterus  acquire  its  additional 
bulk  during  pregnancy,  from  an  increment  of  new  animal  matter? 
If  this  additional  matter  really  did  exist,  it  would  doubtless  be  of 
serious  mischief  in  cases  of  flooding;  as  it  must  necessarily  inter- 
rupt contraction. 


CHAPTER  VII. 

OF  THE  DEVELOPEMENT    OF  THE  PCETUS. 

208.  A  strong  and  certainly  a  laudable  curiosity  is  almost 
always  felt  by  the  student,  to  ascertain  the  progress  of  develope- 
mcnt  of  the  foetus  from  the  moment  of  its  conception,  up  to  the 
full  term  of  gestation.  And  though  our  knowledge  upon  this 
subject  must  necessarily  be  both  limited  and  uncertain,  yet 
enough  is  known,  to  enable  us  to  form  a  tolerably  correct  esti- 
mate of  the  progress,  the  embryo  or  foetus  makes,  up  to  its  final 
developement. 

209.  The  latest  information  upon  this  subject  will  almost  ne- 
cessarily be  the  best;  as  all  that  is  known  upon  this  head,  must 
consist  of  a  series  of  histories  by  different  naturalists,  anatomists, 
&.C.;  we  shall,  therefore,  avail  ourselves  of  the  accuracy  and  in- 
dustry of  Dr.  Beck*  upon  this  point;  and  at  the  same  time  ten- 

*  Elements)  of  Medical  Jurisprudence,  vol.  I.  p.  162. 
12 


90  OF  THE  DEVELOPEMENT  OF  THE  FCETUS. 

der  that  gentleman  our  thanks  for  this,  and  several  other  pieces 
of  valuable  infoi'mation  connected  with  several  of  our  subjects. 

210.  Dr.  Beck  says,  ^'  I  will  premise,  that  the  following  sum- 
mary is  drawn  from  the  observations  of  Aristotle,  Hippocrates, 
Riolan,  Haller,  Rocderer,  Meckel,  Burton,  Baudelocque,  William 
Hunter,  Burns,  Chaussier,  Beclard,  Capuron,  Clarke,  Merriman, 
and  Sammering." 

211.  "From  the  time  of  the  first  evidence  of  impregnation  to 
the  fifteenth  day,  the  produce  of  conception  appears  only  as  a 
gelatinous,  semitransparent,  flocculent  mass  of  a  grayish  colour, 
liquifying  promptly,  and  presenting  no  distinct  formation,  even 
by  the  aid  of  a  microscope.     At  thirty  days,  it  has  the  size  of  a 
large  ant,  according  to  Aristotle,  or  of  a  barley-corn,  according 
to  Burton.     Baudelocque,  however,  observes,  that  it  is  not  larger 
than  the  malleus  of  the  tympanum.     Its  length  varies  from  three 
to  five  lines.     At  six  or  seven  weeks,  its  length  is  almost  ten  lines. 
The  form  and  lineaments  of  the  principal  organs,  and  the  place 
from  which  the  members  are  to  arise,  can  now  be  observed, 
and  it  is  equal  in  size  to  a  small  bee.    At  this  time  also,  the  fluid 
contained  in  the  membranes  is  much  heavier  than  the  embryo. 
At  tv^o  months,  the  length  is  about  two  inches,  and  its  weight 
nearly  two  ounces.     All   the   parts  are  perfectly  distinct,  and 
many  points  of  ossification  are  observed  in  the  head,  trunk,  and 
members.     Sometimes  the  male  sex  may  be  distinguished.     At 
the  third  month,  it  is  about  three  and  a  half  inches  long,  and  be- 
tween two  and  three  ounces  in  weight.     The  nose  and  mouth 
are  formed,  and  the  features  of  the  face  become  more  distinct. 
The  eyes  are  shut,  and  the  eyelids  adhere  together — the  head  is 
longer  and  heavier  than  the  rest  of  the  body — the  umbilical  cord 
is  formed — the  genitals  are  distinct — the  penis,  &c.  are  relatively 
very  large — the  nymphas  are  projecting,  and  the  labia  very  thick. 
At  the  fourth  month,  the  foetus  is  from  five  to  six  inches  long,  and 
weighs  from  four  to  five  ounces.     The  external  parts  all  develope 
themselves,  with  the  exception  of  the  hair  and  nails.     The  great 
relative  proportion  of  the  fluid  of  the  membranes  disappears,  and 
the  foetus  nearly  fills  the  cavity  of  the  uterus.     During  the  fifth 
month,  the  motions  of  the  foetus  are  felt  by  the  mother.     The 
length  is  from  seven  to  nine  inches,  and  the  weight  nine  or  ten 
ounces.     The  brain  is  pulpy,  and  is  destitute  of  circumvolutions 
or  furrows.     The  external   ear  is  completed  about  this  time, 


OF  THE  DEVELOPEMENT  OF  THE  PffiTUS.  91 

though  its  shape,  which  is  like  that  of  a  gently  depressed  circle, 
differs  from  the  ear  after  birth." 

212.  "  In  the  sixth  month,  we  begin  to  find  some  trace  of  fat 
under  the  integuments;  where  previously  nothing  but  a  mass  of 
gelatine  had  been  observed.  The  head  also,  which  before  had 
been  proportionably  large,  becomes  smaller  in  comparison  with 
the  body.  It  is  now,  however,  large  and  soft,  and  the  fontanelles 
are  very  much  expanded.  The  brain  acquires  more  consistence, 
but  is  still  easily  dissolved  ;  and  the  pia  mater  seems  only  to  lie 
over  its  surface,  being  separated  with  great  facility.  The  skin  is 
very  fine,  pliant,  and  thin,  and  of  a  purple  colour,  especially  in 
the  palms  of  the  hands,  the  soles  of  the  feet,  the  face,  lips,  ears, 
and  breasts.  In  males  the  scrotum  is  slightly  developed,  and  of 
a  bright  red  colour;  and  the  testicles  are  still  in  the  abdomen. 
In  females  the  vulva  is  projecting,  and  the  labia  separated  by  the 
protuberance  of  the  clitoris.  The  hair  on  the  head  is  very  thinly 
disposed,  short,  and  of  a  white  or  silvery  colour — the  eyelids  are 
closed ;  the  hair  on  the  eyebrows  and  eyelashes  but  thinly  scat- 
tered, and  the  pupil  is  closed  by  a  membrane.  The  nails  are 
wanting,  or  scarcely  apparent.  The  lungs  are  very  small,  w-hite 
and  compact.  The  heart  is  large,  and  the  liver  very  large,  and 
situated  near  the  umbilicus — the  gall  bladder  contains  only  a 
small  quantity  of  a  nearly  colourless  fluid ;  and  the  meconium  is 
small  in  quantity,  and  is  found  only  in  a. part  of  the  large  intes- 
tines. The  bladder  is  hard  and  pyriform,  and  has  a  very  small 
cavity.  The  ordinary  weight  of  the  foetus,  at  tjiis  time,  is  from 
one  to  two  pounds ;  and  its  length  from  nine  to  twelve  inches 
— the  middle  of  which  is  at  the  abdominal  extremity  of  the 
sternum." 

213.  "At  the  seventh  month,  all  the  parts,  both  external  and 
internal,  are  still  more  developed.  The  skin  assumes  a  rosy 
hue,  and  becomes  more  dense;  and  it  is  covered  with  a  sebaceous 
fluid,  so  as  to  form  a  whitish,  unctuous  covering.  The  eyelids 
are  no  longer  united,  and  the  membrana  pupillaris  separates,  so  as 
to  form  the  pupil.  The  cerebral  pulp  becomes  more  consistent, 
and  its  surface  is  a  little  furrowed,  and  adheres  somewhat  to  the 
meninges.  The  meconium  increases  in  quantity — the  hair  on 
the  head  is  longer,  and  takes  a  deeper  hue.  The  nails  acquire 
more  firmness.  Weight  from  two  to  three  pounds.  Length  from 
twelve  to  fourteen  inches—the  middle  of  which  is  nearer  to  the 
sternum  than  to  the  navel. " 


93  OF  THE  DEVELOPEMENT  OF  THE  FOETUS. 

214.  "At  the  eighth  month,  the  skin  has  acquired  more  den- 
sity, and  is  whiter;  it  is  covered  with  very  fine  white  hairs,  and 
its  sebaceous  covering  is  more  apparent.  The  nails  are  firmer; 
the  hair  of  the  head  longer,  and  more  coloured.  The  breasts  are 
often  projecting,  and  a  lactiferous  fluid  may  be  pressed  from 
them.  The  testicles  in  males  are  frequently  engaged  in  the  ab- 
dominal ring.  In  females  the  vagina  is  covered  with  a  transpa- 
rent mucus.  The  grooves  in  the  cerebral  substance  gradually 
become  more  marked;  the  spinal  marrow,  pons  varollii,  and 
medulla  oblongata,  acquire  a  remarkable  consistence,  and  even 
firmness.  The  lungs  are  of  a  reddish  colour — the  liver  preserves 
nearly  its  former  relative  size,  but  it  is  more  remote  from  the 
navel — the  fluid  in  the  gall  bladder  is  of  a  yellowish  colour,  and 
has  a  bitter  taste.  The  weight  at  this  time  is  from  three  to  four 
and  sometimes  five  pounds.  Length,  sixteen  inches  or  more — 
the  middle  of  which  is  nearer  to  the  navel  than  to  the  sternum." 

215.  «  At  the  ninth  month  ossification  is  more  complete — the 
head  is  large,  but  it  has  a  considerable  degree  of  firmness.  The 
bones  of  the  cranium,  though  movable,  touch  each  other  with 
their  membranous  margins— the  fontanelles  are  smaller;  the  hair 
is  longer,  thicker  and  of  a  darker  colour;  and  the  nails  become 
more  solid  and  prolonged  to  the  extremity  of  the  fingers.  The 
convolutions  on  the  surface  of  the  brain  are  more  numerous — the 
eineritious  portions  begin  to  be  distinguished  by  their  colour; 
and  though  the  lobes  which  compose  the  cerebrum,  retain  their 
former  softness,  yet  the  cerebellum,  and  the  basis  of  the  cere- 
brum, have  acquired  a  remarkable  consistence.  The  head  mea- 
sures longitudinally,  from  the  forehead  to  the  occiput,  four 
inches,  to  four  inches  and  a  quarter;  and  transversely,  from  three 
and  a  half  to  four  inches.  The  abdomen  is  now  large  and 
round.  The  lungs  are  redder  and  larger.  The  canalis  arteriosus 
is  large,  and  its  coats  are  thicker  and  denser  than  formerly.  The 
meconium  fills  nearly  the  whole  of  the  intestines,  and  the  blad- 
der contains  urine.  In  fact,  the  digestive  apparatus,  the  heart, 
and  the  lungs,  are  in  a  state  fit  to  commence  extra-uterine  life. 
The  length  varies  from  nineteen  to  twenty  inches  or  more — the 
middle  of  which  is  at  the  navel,  or  a  very  little  below." 

216.  The  detail  of  the  progress  of  developement  just  given 
must  however  be  looked  upon  but  as  a  general  scheme,  to 
which  many  exceptions  will  necessarily  present  themselves,  nor 
can  a  nearer  approach  be  well  made;  since  almost  every  coun- 


OP  THE  DEVELOPEMENT  OP  THE  PCETUS.  93 

try  will  present  individual  differences;  especially,  in  the  weights 
and  measurements  of  the  embryo  and  the  foetusj  consequently 
the  estimates  here  given,  must  not  be  regarded  as  rigidly  exact. 
Indeed  our  individual  experience,  were  it  compared  with  many 
of  these  statements,  would  be  at  variance  with  them;  but  not  so 
extensively  as  to  invalidate  the  general  estimate. 

217.  Nothing  perhaps  will  place  these  observations  in  a 
clearer  light,  than  giving  the  standard  average  weights  of  the 
newly-born  foetus  in  different  countries,  as  has  been  collected 
with  so  much  industry  by  Dr.  Beck,  and  whose  account  we  will 
make  use  of. 

218.  "The  weight  of  the  foetus  at  full  time  of  utero-gestation, 
has  been  the  subject  of  numerous  observations,  and  as  a  prelimi- 
nary remark,  it  must  be  noticed,  that  this  differs  according  to  the 
conformation  and  habits  of  the  parent  and  the  sex  of  the  child. 
Healthy  females  residing  in  the  country,  or  engaged  in  active 
occupations,  have  generally  the  largest  children.  Male  children 
also  generally  weigh  more  than  female  ones." 

219.  "In  Germany,  Roederer  found  the  weight  in  one  hundred 
and  thirteen  cases,  to  vary  from  seven  to  eight  pounds,  and  he 
lays  it  down  as  a  rule,  that  it  is  rarely  less  than  six  pounds.  Dr. 
Hunter  states  that  Dr.  Macauley  examined  the  bodies  of  several 
thousand  new  born  and  perfect  children,  at  the  British  Lying-in 
Hospital,  and  found  that  the  weight  of  the  smallest  was  about 
four  pounds,  and  the  largest  eleven  pounds  two  ounces;  but  by 
far  the  greatest  number  was  from  five  to  eight  pounds.  Dr. 
Joseph  Clarke's  inquiries  furnish  similar  results." 

220.  "The  greatest  proportion  of  both  sexes  according  to  him, 
weighed  seven  pounds,  yet  there  were  more  males  than  females 
found  above,  and  more  females  than  males  below  that  standard. 
Thus  out  of  sixty  males  and  sixty  females,  thirty-two  of  the 
former,  and  twenty-five  of  the  latter,  weighed  seven  pounds, 
and  there  were  fourteen  females,  and  only  six  males,  who 
weighed  six  pounds.  On  the  other  hand,  there  were  sixteen 
males,  but  only  eight  females  who  weighed  eight  pounds." 

221.  "Taking  then  the  average  weight  of  both  sexes,  it  will 
be  found  that  twelve  males  are  as  heavy  as  thirteen  females. 
The  exact  average  weight  of  male  children,  according  to  Dr. 
Clarke,  was  seven  pounds  five  ounces  and  seven  drachms;  and 
that  of  female,  six  pounds  eleven  ounces  and  six  drachms." 

222.  "  Dr.  Clark  of  Dublin,  found  the  weight  to  vary  from 


94  OP  THE  DEVELOPEMENT  OF  THE  FffiTUS. 

four  to  eleven  pounds.  Dr.  Merriman  states  in  his  lectures,  that 
he  delivered  one  that  weighed  fourteen  pounds,  (it  was  born  dead,) 
and  Dr.  Croft  delivered  one  alive,  weighing  fifteen  pounds."* 

223.  "In  France  the  weight  seems  to  be  less  than  in  England. 
Of  1554  examined  by  Camus,  the  greatest  weight  was  nine 
pounds;  and  of  this  there  were  sixteen  instances — the  ordinary 
from  five  to  seven,  and  the  average,  six  pounds  and  about  a  quar- 
ter; there  were  thirty-one  instances  in  which  the  weight  was  as 
low  as  three  pounds,  Baudelocque,  however,  states  that  he  saw 
several  instances  in  which  the  weight  was  about  ten  pounds — a 
few  where  it  was  twelve,  and  one  of  thirteen.  Subsequent  ob- 
servations on  twenty  thousand  ciiildren  at  I'hospice  de  la  JMater- 
nite  in  Paris,  have  shown  a  few  instances  where  it'has  been  one 
hundred  and  sixty-eight  ounces;  that  is,  ten  pounds  and  a  half; 
and  this  is  the  highest  term.  Capuron  mentions,  that  he  has  seen 
two  instances  where  the  children  weighed  twelve  pounds." 

224.  "We  shall,  as  a  deduction  from  the  above  observations, 
be  probably  most  correct  in  allowing  the  average  to  vary  from 
five  to  eight  pounds.  Dr.  Willoughbyt  informs  us,  that  as  far  as 
his  observations  have  extended,  the  average  weight  of  children  is 


•  From  these  remai'ks  It  would  seem,  that  it  is  very  rare  in  Europe,  at  least 
in  British  Europe,  to  meet  witli  children  weighing  more  than  twelve  pounds. 
In  this  country,  as  far  as  our  experience  goes,  it  is  not  very  unfrequently  met 
witli,  if  compai-isons  by  the  eye  do  not  greatly  deceive  us.  I  dehvered  one  wo- 
man of  three  chikh-en,  (at  three  different  births,  and  aU  males,)  which  appeared 
of  the  same  size  at  birth;  and  from  the  very  large  size  of  the  one  I  first  dehver- 
ed her  of,  I  prevailed  upon  tlie  parents  to  permit  me  to  weigh  it — it  weighed 
without  clothing,  fifteen  pounds  and  a  half — the  two  others  were  not  weighed, 
but  appeared  to  be  of  equal  bulk.  I  have  met  with  two  ascertained  cases  of 
fifteen  pounds,  and  several  I  beheved  to  be  of  equal  weight.  I  will  give  tlie 
measurements  of  a  cliild  at  bh'th,  the  weight  of  wliich  was  not  ascertained,  fi-om 
prejuchces  being  entertained  against  the  experiment.  This  child,  (a  male,)  was 
dehvered  alive  by  the  forceps;  as  was  its  brother,  eighteen  months  before;  and 
which  I  believe,  was  of  equal  size. 

Round  the  forehead  and  vertex,  16  inches  4-8ths. 

Round  the  shoulders,  19  inches  5-8ths. 

Round  the  arm  below  the  elbow,  5  inches  6-8ths. 
Velpeau  says,  that  a  new-born  child  of  eight  or  nine  pounds,  is  enormous; 
and  indirectly  calls  in  question  the  veracity  of  those  who  have  affirmed  they 
have  witnessed  much  greater  weights — did  M.  V.  live  in  this  country,  he  miglit 
often  be  convinced  that  such  tilings  do  occur,  and  that  not  so  unfrequently,  as 
to  make  tliem  extremely  rare. 

t  Professor  of  Midwifery  at  the  coUege  of  Physicians  and  Surgeons  of  the 
Western  District  of  New  York. 


OP  THE  DEVELOPEMENT  OP  THE  PCETrtTS.  95 

upwards  of  seven  pounds."  p.  1G7,  &c.     The  result  of  Dr.  W.'s 
experience  would,  we  believe,  accord  with  our  own. 

225.  "  The  length  of  the  foetus  at  full  time,  varies  much  less 
than  its  weight.  Kocderer  concludes  from  his  examuiations,  that 
the  average  length  of  a  male  child,  is  twenty  incK^g  and  a  third, 
while  that  of  a  female  is  nineteen  inches  and  seventeen-eighteenths. 
Petit  assigns  twenty-one  inches  as  the  usual  length.  Hutchinson 
says,  it  is  ordinarily  from  nineteen  to  twenty-two  inches,  and 
seventeen  and  twenty-six  inches  will  include  the  two  extremes,* 
excepting  some  very  rare  cases,  while  Fodere  and  Capuron  place 
the  extremes  from  sixteen  to  twenty-three  inches.  This  last  au- 
thor attaches  great  importance  to  the  difference  in  the  proportion 
between  the  length  of  the  superior  and  the  inferior  parts  of  the 
body,  and  he  conceives  that  attention  to  this,  is  one  of  the  best 
modes  of  verifying  the  age  of  the  foetus.  As  a  general  rule,  there 
will  be  an  equilibrium  between  the  upper  and  lower  parts  of  the 
body  at  the  ordinary  term  of  gestation,  and  the  navel  will  be  at 
the  middle  of  the  body,  or  nearly  so.  Before  that  time,  the 
middle  will  approach  nearer  the  head." 

226.  "  It  is  evident,  that  the  signs  drawn  from  the  structure, 
weight,  and  dimensions  of  the  child,  are  liable  to  some  variety, 
and  this  depends  on  various  circumstances,  such  as  the  age  and 
vigour  of  the  mother,  her  mode  of  life,  the  diseases  to  which  she 
may  have  been  subject,  and  probably  the  climate  in  which  she 
lives."  p.  170. 

227.  From  what  has  been  said,  it  must  be  certain,  that  the 
foetus,  like  every  other  product,  will  be  liable  to  a  variety  of  con- 
tingencies in  its  progress  from  the  germinal,  to  the  fully  expanded 
state;  and  consequently,  that  the  laws  of  developement  may  be 
imperfectly,  or  irregularly,  too  slowly,  or  too  rapidly  performed, 
which  will,  as  one  or  the  other  of  these  conditions  prevail,  give  rise 
to  a  considerable  difference  in  the  appearance  of  the  newly  born 
child. 

228.  If  the  laws  of  developement  be  imiDorfectly  or  irregularly 
performed,  the  frotus  may  be  defective  in  some  of  its  parts ;  or  it 
may  be  natural,  or  excessive  in  other  portions  of  its  body.  If 
too  slowly  developed,  it  will  exhibit  the  marks  of  immaturity, 
but  not  (perhaps  necessarily,)  of  imperfection.  If  this  be  too 
rapidly  performed,  there  will  be  evidences  of  it,  in  the  excessive 

*  I  once  delivered  a  child,  that  measured  twenty-sevcn  inches  in  length. 


96  OP  THE  DEVELOPEMENT  OP  THE  PCETUS. 

though  perfect  size  of  all  its  members.  In  a  medico-legal  point 
of  view,  it  is  sometimes  of  great  consequence  to  decide  between 
immaturity  of  developement,  and  the  imperfection  of  develope- 
ment  of  the  foetus ;  the  first  has  relation  to  the  time  it  may  have  tar- 
ried in  the  |^rus;  while  the  second  depends  upon  the  manner 
in  which  developement  has  proceeded,  or  has  been  performed  in 
utero.  These  two  conditions  of  the  foetus,  it  will  be  easily  per- 
ceived, may  have  a  very  important  influence  in  certain  cases,  as 
one  or  other  may  exist.  On  the  one  hand,  when  developement 
is  performed  too  rapidly,  or  excessively,  it  may  give  rise  to  very 
important  consequences,  as  we  shall  attempt  to  show  presently. 

229.  While  on  the  other,  the  instances  of  retarded  developement 
are  by  no  means  uncommon;  and  when  this  occurs,  it  may  oc- 
casion much  error  of  deduction ;  especially,  when  this  is  based 
upon  the  mere  appearance  of  the  child.  In  some  instances  it 
may  involve  the  happiness  and  character  of  the  individuals  with 
whom  this  deficiency  of  organic  power  may  prevail ;  it,  there- 
fore, merits  serious  attention.  And  again,  causes  may  operate  to 
hasten,  or  rather  to  augment  developement.  So  much  so  is  this 
the  case  sometimes,  as  to  lead  to  conclusions  equally  disastrous 
to  the  reputation  and  happiness  of  the  individuals  concerned,  in 
the  event  of  its  becoming  a  medico-legal  question.  We  shall 
cite  an  example  of  each  kind. 

230.  One  of  the  most  remarkable  of  the  first  kind,  is  that,  re- 
lated in  the  "Clinique  d'Accouchemens  de  Pavie,"  reported  by 
Dr.  Lovate.*  This  case  is  recorded  as  an  instance  of  premature 
delivery  at  the  fifth  month,  though  the  woman  believed  herself 
to  have  arrived  at  full  term.  The  reporter  declares,  that, "  every 
appearance  announced  the  opinion  of  the  woman  to  be  correct ; 
this  was  her  sixth  pregnancy;  and  she  had  been  previously  to 
impregnation  perfectly  regular  in  her  catamenial  discharges. 
Eight  menstrual  periods  had  passed  without  any  discharge;  the 
abdomen  swelled  progressively  and  regularly ;  the  child  was  felt 
for  several  months ;  the  neck  of  the  uterus  was  very  short,  and 
the  lower  segment  of  the  uterine  cavity  was  much  developed ; 
the  head  of  the  foetus  was  easily  felt,  but  was  ver}'  movable.  The 
uterus  reached  to  the  epigastric  region ;  and  the  abdomen  was 
very  voluminous.  On  the  2Sth  November,  1824,  this  woman  was 
delivered  naturally  of  a  living,  but  a  feeble  child,  and  appeared 

*  Revue  Mcclicale,  Vol.  III. 


OP  THE  DEVELOPEMENT  OF  THE  FffiTUS.  97 

not  to  be  more  than  five  months ;  it  lived  some  hours.  It  weighed 
two  pounds  ten  ounces,  it  measured  thirteen  inches  and  nine 
lines,  and  there  was  a  great  disproportion  in  length,  between  the 
inferior  and  superior  parts,  from  about  the  umbilicus.  The  waters 
w^eighed  more  than  ten  pounds,  and  escaped  with  the  dependen- 
cies of  the  foetus,"  This  extraordinary  accumulation  of  the  liquor 
amnii,  is  considered  as  the  cause  of  the  error  of  the  period  of 
gestation,  and  of  the  premature  birth  of  the  child. 

231.  Though  the  reporter  of  this  case,  looks  upon  the  great 
quantity  of  water  as  the  cause  of  error  in  the  woman's  calcula- 
tion of  her  advancement  in  pregnancy,  as  well  as  the  cause  of 
the  premature  delivery,  (as  he  j,hinks  it;)  yet  the  history  of  the 
case  appears  to  afford  the  strongest  ground  for  the  belief,  that 
the  woman  went  her  full  time;  and  that  the  under-size  and 
weight  of  the  child  was  owing  to  its  incomplete  developement.  In 
the  first  place,  eight  menstrual  periods  had  elapsed  without  dis- 
charges, before  the  birth  of  the  foetus;  and  this  took  place  with  a 
woman,  who  had  been  perfectly  regular  before.  Now,  though 
we  do  not  hold  this  circumstance  in  itself  to  be  conclusive,  yet  it 
must  be  looked  upon  as  strongly  presumptive,  that  the  arrest  of 
the  catamenia  was  owing  to  impregnation;  as  the  abdomen  began 
to  enlarge  regularly  from  this  time;  and  the  stirrings  of  the  child 
were  perceived  several  months.  If  we  add  to  these  facts,  the 
condition  of  the  neck  of  the  uterus,  the  ascent  of  its  fundus  to 
the  epigastrium,  and  the  facility  with  which  the  head  of  the  child 
was  felt,  they  would  seem  to  be  conclusive,  that  the  woman  had 
gone  to  the  full  period  of  utero-gestation.  Besides,  the  weight 
and  measurement  of  the  child  vastly  exceeded  those  of  a  foetus 
of  but  five  months. 

232.  In  general,  a  foetus  at  five  months  measures  agreeably  to 
Hamilton,  and  our  own  frequent  observation,  not  more  than 
from  six  to  seven  inches,*  and  weighs  but  a  few  ounces;  whereas, 
in  the  case  in  question,  the  foetus  measured  double  this  number 
of  inches,  and  weighed  more  than  six  times  the  ordinary  weight 
of  one  at  five  months.  Besides,  it  is  expressly  stated,  that  the 
mother  felt  the  stirrings  of  the  child  during  several  months  pre- 
viously to  its  birth.  Now  the  common  period  of  quickening  is 
about  the  fourth  month — it  is  true,  that  this  circumstance  if  taken 

*  Dr.  Beck  says,  (211,)  the  length  is  from  seven  to  nine,  and  weight  nine 
or  ten  ounces;  we  are  certain  tliat  botli  tlie  measurement  and  weight,  are  ex- 
cessive as  a  general  rule. 

13 


98  OP  THE  DEVELOPEMENT  OF  THE  FCETUS. 

alone,  might  be  liable  to  some  objection;  as  women  have  de- 
clared they  have  perceived  this  sensation  as  early  as  the  twelfth 
week  ;  but  if  the  regular  developement  of  the  uterus  be  taken  into 
consideration,  (and  it  is  declared,  that  at  the  time  of  delivery,  its 
fundus  had  reached  the  epigastrium,)  it  justly  acquires  much,  and 
deserved  weight. 

233.  The  author  of  the  observation,  is  of  opinion,  as  we  have 
stated,  that  the  extraordinary  accumulation  of  the  waters  was  the 
cause  of  the  error  in  the  calculation  of  the  period  of  gestation,  as 
well  as  what  he  supposes,  the  premature  expulsion  of  the  foetus; 
but  we  cannot  agree  with  him  in  his  conclusions,  for  the  follow- 
ing reasons:  1st.  Because,  it  is  stated,  that  after  the  cessation  of 
the  menstrual  discharge,  the  belly  increased  "  progressively  and 
regularly ;"  and  consequently,  if  this  enlargement  depended,  as 
is  supposed,  upon  liquor  amnii  being  enclosed  within  the  uterus, 
the  liquor  amnii  must  have  existed  before  conception  had  taken 
place ;  a  circumstance  hitherto,  we  are  disposed  to  believe,  has 
never  been  insisted  on.  2d.  Because  this  explanation  supposes 
that  the  liquor  amnii  can  be  furnished  independently  of  the 
amnios;  for  if  the  uterus  was  regularly  developed,  as  it  is  declared 
to  have  been,  from  the  first  stoppage  of  the  catamenia;  and  if  this 
developement  was  occasioned  by  the  liquor  amnii,  that  fluid  must 
have  been  produced  by  the  covering  of  the  foetus;  and  if  this  be 
admitted,  the  foetus  must  have  existed  as  early  as  the  liquor  am- 
nii ;  and  if  this  be  granted,  it  must  date  its  age  from  the  time  the 
menses  were  interrupted,  which  will  make  it  a  child  at  full 
period;  but  one,  which  had  been  imperfectly  developed.  3d.  Be- 
cause, it  is  a  very  common  occurrence,  to  have  a  large  collection 
of  the  liquor  amnii,  when  the  foetus  is  but  ill-developed,  where 
there  is  no  suspicion  that  the  woman  has  not  arrived  at  full  time. 
4th.  Because,  in  the  case  in  question,  there  was  no  preternatural 
distention  of  the  uterus,  to  render  it  probable,  that  it  was  deve- 
loped in  so  short  a  period  as  five  months,  to  a  size  equal  to  that 
at  the  last  period  of  gestation,  from  the  mere  excess  of  the  liquor 
amnii,  as  the  united  weights  of  the  foetus,  (2  lbs.  10  oz. )  and  of 
the  waters,  (10  lbs.)  will  not  exceed  the  average  weights  of  these 
two  substances  at  the  ordinary  full  period  of  gestation. 

234.  It  may  be  said,  that  the  liquor  amnii  was  so  largely  and 
suddenly  furnished,  as  to  give  the  uterine  developement  the  ap- 
pearance of  maturity;  though  the  woman  may  have  been  but  five 
months  impregnated:  but  this  supposition  is  entirely  destroyed 


OF  THE  DEVELOPEMENT  OP  THE  PffiTUS.  9» 

by  the  facts  connected  with  the  first  interruption  of  the  mensesj 
for  it  is  expressly  stated,  that  the  belly  began  to  swell  "  regularly 
and  progressively,"  and  that  "  the  neck  of  the  uterus  was  very 
short,"  and  "  that  the  lower  segment  of  its  cavity  was  much 
developed."  Besides,  we  must  insist,  that  there  is  no  example 
in  our  opinion  extant,  of  a  foetus  of  five  months,  weighing  two 
pounds  ten  ounces.  Again,  the  woman  herself  was  of  opinion, 
that  she  had  arrived  at  her  full  time;  and  her  impression  on  this 
subject  is  certainly  entitled  to  some  consideration,  as  she  had  had 
five  children  before,  and  could  not  very  well  be  mistaken  when 
she  said  she  had  felt  her  child  several  months,  before  the  period 
of  labour. 

235.  I  would  inquire  moreover,  whether  any  accoucheur 
could  easily  feel  the  head  of  a  foetus  by  an  examination  per  va- 
ginam,  at  the  fifth  month  of  pregnancy.  Indeed,  at  this  period 
it  is  not  always  safe  to  declare  the  woman  to  be  pregnant,  much 
less  to  determine,  that  the  head  is  the  presenting  part,  and  that  it 
is  very  movable ;  for  as  the  neck  of  the  uterus  has  lost  nothing 
of  its  length,  at  this  time,  and  as  the  uterine  parietes  are  very  rigid 
and  pretty  thick  about  this  period,  we  are  of  opinion  that  much 
difficulty  would  attend  forming  a  decision  that  would  be  free  from 
all  error.  As  regards  ourselves,  we  have  no  hesitation  to  believe 
this  case  to  be  one  of  retarded  or  imperfect  developement  of  the 
foetus;  and  that  its  application  to  medico-legal  investigations, 
may  be  highly  important. 

236.  We  have  stated  above,  that  the  developement  of  the  foetus 
may  be  more  rapid  and  perfect  than  ordinary,  as  well  as  unusual- 
ly defective;  and  when  this  takes  place,  it  may  also  give  rise  to 
very  serious  consequences,  if  the  possibility  of  such  an  occur- 
rence become  a  question,  before  a  legal  tribunal.  As  we  are  of 
opinion  that  this  pretty  frequently  liappens,  we  will  relate  a  case, 
which  had  nearly  become  a  subject  of  inquiry,  before  one  of  our 
courts,  by  a  suit  for  a  divorce. 

237.  In  November,  1810,  I  was  called  to  attend  a  female  in 
labour  with  her  first  child.  The  woman  had  been  very  suddenly 
attacked  with  severe  pains,  in  consequence,  as  was  supposed,  of 
great  agitation  of  mind.  On  examination,  I  found  the  uterus  was 
not  completely  developed ;  as  a  portion  of  the  neck  was  still 
to  be  felt.  I  inquired  of  the  patient,  whether  she  thought  herself 
at  her  full  period;  she  answered,  no;  she  was  but  seven  months 
gone. — After  several  hours  of  very  severe  suflering,  she  was  de- 


100  OP  THE  DEVELOPEMENT  OP  THE  FffiTUS. 

livered  of  a  large  boy;  at  least,  large  for  seven  months.  I  how- 
ever made  no  observations  upon  the  case  at  the  moment,  as  I  was 
an  entire  stranger  to  the  circumstances  of  my  patient ;  though 
the  size  of  the  child  was  remarked  upon  by  an  old  woman,  mother 
of  the  husband,  who  said,  it  was  "  the  finest  seven  months'  child 
she  had  ever  seen."  It  is  certain,  the  child  bore  every  mark  of 
greater  maturity  than  is  usual  with  children  born  at  the  seventh 
month  of  utero-gestation. 

238.  Some  months  after  this  period,  I  was  called  upon  and  ex- 
amined before  a  magistrate  and  two  lawyers;  this  was  a  prelimi- 
nary step  to  a  suit  for  divorce,  which  was  intended  should  be  sued 
for  by  the  husband  of  my  patient,  if  certain  opinions  derived 
from  me,  were  favourable  to  such  an  undertaking. 

239.  The  following  circumstances  were  alleged  on  the  part  of 
the  intended  prosecution,  before  the  magistrate  and  the  two  law- 
yers; 1st.  That  at  the  period  of  the  birth  of  the  child,  but  seven 
months  had  elapsed,  since  the  marriage  of  the  parties;  2d.  And 
that  at  the  time  of  the  marriage,  the  husband  had  been  from  sea 
but  two  days,  and  this  after  an  absence  of  some  months.  3d.  That 
at  the  end  of  seven  months  the  wife  was  delivered  of  a  full-grown 
child.*  It  was  therefore  declared,  that  the  woman  was  pregnant 
before  marriage,  and  that,  not  by  her  husband;  a  bill  of  divorce 
was  therefore  intended  to  be  prayed  for. 

240.  On  the  part  of  the  wife,  it  was  proved,  she  had  sustained 
an  irreproachable  character;  that  she  was  an  industrious,  domes- 
tic woman;  not  visited  by,  or  known  to  associate  with  any  man 
in  particular;  that  she  had  during  the  whole  time  lived  with  the 
mother  of  her  husband,  and  that  she  had  had  her  menstrual  pe- 
riod but  a  few  days  before  her  marriage,  and  that  she  had  not 
had  them,  since  her  marriage. 

241.  My  evidence  went  to  say,  that  at  the  period  of  labour, 
the  neck  of  the  uterus  was  developed  rather  more  than  was  usual 
at  the  seventh  month,  but  was  not  effaced;  which  gave  rise  on 
my  part  to  the  question  as  above  stated,  whether  the  patient 
thought  herself  at  her  full  term,  and  which  drew  from  her  the 
answer,  "  that  she  was  but  seven  months  advanced  in  her  preg- 
nancy;" and  that  my  opinion  and  belief  was,  that  she  was  not  in 
error  as  regarded  her  calculation;   though  the  child  was  very 

*  It  was  stated,  that  after  I  had  left  the  house,  it  was  suggested  liy  some  one 
present,  that  it  might  be  well  to  weigh  the  childj  this  was  done;  and  it  was  as- 
certained to  weigh  between  six  and  seven  pounds. 


OF  THE  DEVELOPEMENT  OF  THE  FffiTUS.  101 

considerably  larger  than  is  usual  at  the  seventh  month.  That 
violent  mental  excitement  was  a  frequent  cause  of  abortion,  and 
of  premature  delivery  ;  and  it  had  been  proved,  that  this  woman 
had  experienced  great  mental  anxiety,  as  well  as  felt  great  anger, 
the  day  previous  to  her  experiencing  anything  like  the  pains  of 
labour;  and  that  this  mental  agitation  might  have  occasioned  the 
premature  delivery. 

242.  That  the  developement  of  the  foetus  is  by  no  means  re- 
gular; that  it  is  notorious,  that  some  women  bear  much  larger 
children  than  others ;  that  the  average  weight  of  a  newly-born 
child  is  fixed  in  this  country,  at  between  seven  and  eight  pounds; 
now  it  must  be  evident,  from  an  average  being  fixed  upon,  that 
there  must  necessarily  be  many  children  whose  weights  must 
exceed  the  stipulated  weight  or  average ;  and  many  others  fall 
below  it.  And  though  it  was  my  belief,  that  the  weiglit  of  the 
child  in  question,  was  nearly  equal  to  the  average  proportion ; 
yet  that  this  in  itself  did  not  by  any  means  prove  it  had  arrived 
at  full  time;  as,  all  such  children  whose  respective  weights  may 
exceed  the  average,  and  particularly  those  which  may  weigh 
from  twelve  to  fifteen  pounds  at  birth,  (a  thing  not  very  unusual,) 
must  necessarily  have  weighed  more  than  the  average  at  seven 
months;  and  consequently,  the  weight  of  the  child  cannot  mark 
the  period  of  gestation  with  so  much  precision,  as  to  render  it 
free  from  all  error. 

243.  That  the  fact  just  stated,  must  strike  every  body  as  an 
irresistible  truth ;  and  consequently,  that  this  might  have  hap- 
pened in  the  case  in  question  ;  or  in  other  words,  as  it  is  indis- 
putable, that  many  children  at  birth  exceed  the  average  weight, 
it  must  follow,  that  the  lesser  weight  must  be  attained  before 
the  greater ;  and  that  in  cases  of  excessively  heavy  children,  six 
or  seven  pounds  would  not  be  an  extravagant  weight  for  a  child 
at  seven  months,  that  might  weigh  nearly  double,  if  carried  to 
the  full  period  of  utero-gestation ;  and,  that  there  could  be  no 
possible  reason  assigned,  why  this  might  not  have  happened,  in 
the  case  in  question. 

244.  The  husband  was  so  entirely  satisfied  of  this  possibility, 
that  he  abandoned  all  further  intention  of  a  prosecution. 

245.  A  diseased  condition  of  the  mother  may  sometimes  inter- 
rupt the  regular  developement  of  the  foetus;  but  this  is  by  no 
means  so  frequent,  as  might  at  first  sight  be  imagined,  even  where 
this  might  reasonably  be  expected.     For  in  cases  of  long-pro- 


102  OF  THE  DEVELOPEMENT  OP  THE  FCETUS. 

tracted  illness,  where  the  mother  has  suffered  great  emaciation, 
the  child  has  often  been  found,  contrary  to  all  expectation,  well 
developed,  and  apparently  healthy.  Yet  it  now  and  then  occurs, 
that  the  increase  of  the  foetus  has  not  kept  pace  with  the  period 
of  utero-gestation ;  an  instance  of  this  kind  fell  under  my  own 
observation,  and  in  which  there  could  be  no  possible  error  in 
the  calculation,  if  any  reliance  can  be  put  upon  human  assevera- 
tion.    Mrs. was  taken  in  labour  at  the  end  of  the  seventh 

month  of  gestation,  and  was  speedily  delivered  of  a  foetus  of 
about  five  inches  in  length,  and  might  probably  have  weighed 
three  ounces ;  it  breathed  very  imperfectly  a  few  minutes,  and 
then  died. 

246.  Upon  my  declaring  to  my  patient,  that  she  had  made  a 
great  mistake  in  her  calculation,  as  the  child  could  not  at  farthest 
be  more  than  five  months,  she  said  it  was  impossible  from  cir- 
cumstances that  any  error  could  exist ;  and,  that  she  was  every 
way  certain,  it  must  be  full  seven  months.  Presuming  what 
might  be  the  "  circumstances"  alluded  to,  I  inquired  of  the  hus- 
band, whether  my  conjecture  relative  to  them,  (namely,  that  no 
intercourse  had  taken  place  for  that  length  of  time,)  were  cor- 
rect; he  assured  me  they  were  ;  as  the  health  of  his  wife  had 
so  rapidly  declined  at  about  that  time,  as  to  prevent  any  union 
from  taking  place. 

247.  Again,  we  are  intimately  acquainted  with  a  lady,  (whom 
we  have  delivered  of  nine  children  at  full  term,)  who  never  has 
produced  a  child  that  would  have  weighed  at  birth,  five  pounds. 
Yet  this  lady  enjoyed  an  uninterrupted  state  of  health;  made  an 
excellent  nurse;  and  at  the  end  of  a  year,  her  children  were  as 
large  and  as  healthy  as  children  usually  are  at  this  period.  This 
lady  was  subject  to  no  disease  during  gestation  ;  she  did  not  even 
suffer  the  usual  penalties  of  pregnancy;  for  she  was  exempt  from 
both  nausea  and  vomiting. 

248.  In  treating  of  subjects,  which  have  a  relation  to  medical 
jurisprudence,  it  may  be  thought  by  some,  I  have  rather  wan- 
dered from  the  strict  path,  which  my  professed  object  points  out. 
But  in  this  I  do  not  agree.  First:  Because  I  do  not  meddle 
with  any  subject  of  a  medico-legal  kind,  that  has  not  an  intimate, 
and  perhaps  entire  connexion  with  midwifery.  Second:  Be- 
cause, on  the  intimate  knowledge  of  this  branch,  some  of  the 
most  important  testimony  almost  exclusively  depends.  Third: 
Because,  some  of  the  most  frequent,  as  well  as  interesting  objects 


OP  THE  ACTION  OF  THE  UTERUS.  103 

of  medical  jurisprudence,  as  infanticide,  supposed  pregnancy, 
supposed  delivery,  rape,  &c,  are  dependant  almost  altogether, 
upon  the  evidence  of  the  accoucheur.  Fourth:  because,  there 
are  points  in  each  of  the  cases  just  named,  which  can  only  be 
elucidated  by  the  experienced  practitioner  of  midwifery.  Fifth: 
Because,  there  is  much  ignorance  as  well  as  discrepancy  betray- 
ed in  the  testimony  of  physicians,  who  may  practise,  (and  even 
extensively,)  this  branch,  when  called  into  a  court  of  justice, 
from  the  want  of  the  knowledge  of  the  subjects,  at  which  we  have 
rather  glanced,  than  professedly  treated. 

249.  Besides,  in  doing  this,  I  hoped  to  awaken  an  interest  to 
the  subject  of  medical  jurisprudence  in  those,  (and  they  are  by 
very  far  the  greater  number,)  who  have  hitherto  paid  no  atten- 
tion to  the  subject,  by  bringing  before  them  quotations  from  Dr. 
Beck's  admirable  work  on  this  subject,  and  thus  induce  them  to 
possess  themselves  of  it. 


CHAPTER  VIII. 

OF  THE  ACTION  OF    THE  UTERUS. 

250.  The  uterus  exerts  two  kinds  of  action;  first,  that  action 
which  tends  to  reduce  this  organ  to  its  original  size  after  having 
been  distended, and  the  distending  cause  has  been  removed;  this 
is  called  by  Baudelocque  and  others,  the  tonic  action  of  the  ute- 
rus. This  action  is  performed  by  all  the  fibres  of  this  organ 
gathering  themselves  up  towards  a  common  centre;  but  more  es- 
pecially, by  that  class  of  fibres  we  shall  denominate  the  "  circu- 
lar fibres;^'  the  other  fibres,  or  those  we  shall  call  the  lono-itudi- 
nal,  not  acting  with  a  force  equal  to  the  other;  hence  the  length- 
ened form  of  the  uterus. 

251.  The  tonic  action  of  the  uterus  can  be  exerted  in  various 
degrees,  as  it  may  possess  its  inherent  powers  in  a  greater  or  lesser 
state  of  perfection;  it  may  exist  under  the  following  conditions, 
and  varieties:  1st.  It  may  act  with  the  most  perfect  uniformity 
and  success  for  the  purposes  for  which  it  is  intended.  2d.  It  may 
be  impaired  so  as  to  act  transitorily  and  feebly.  3d.  It  may  act 
with  force  at  one  moment,  and  cease  the  next.     4th.  It  may  act 


104  OF  THE  ACTION  OF  THE  UTERUS. 

partial!}-;  lliat  is,  the  fundus  may  contract,  and  the  body  and 
neck  be  flaccid;  the  body  may  contract,  and  fundus  and  neck  be 
relaxed;  the  neck  may  contract,  and  the  body  and  fundus  be  in 
a  state  of  atony;  the  body  and  fundus  may  contract,  and  the 
mouth  be  relaxed;  when  these  occur,  different  phenomena  pre- 
sent themselves.  Leveret  and  others  have  admitted  the  tonic 
power  of  the  uterus  to  continue  even  after  visible  life  had  ceased; 
and  however  much  this  circumstance  may  excite  our  surprise,  or 
challenge  our  belief,  it  is  nevertheless  authenticated  by  various 
testimony.  The  latest  instance  of  this  kind  I  have  met  with,  is 
recorded  in  the  Edin.  jMed.  and  Surgical  Journal,  No.  VI.  of  new 
series,  p.  431,  and  related  as  follows,  by  professor  Herrmann,  of 
Bern. 

252.  "  On  the  third  day  after  the  death  of  a  young  woman  who 
was  in  her  sixth  month  of  pregnancy,  the  nurse  heard  a  loud 
noise  proceed  from  the  corpse.  A  physician  was  immediately 
sent  for,  who,  on  his  arrival,  found  that  the  deceased  had  brought 
forth  twins,  which  were  enclosed  in  a  membrane  quite  entire,  and 
not  in  the  least  putrid.  The  placenta  only  appeared  to  have  suf- 
fered from  the  effects  of  putrefaction." 

253.  Leroux  also  mentions  a  case  of  the  contractile  force  con- 
tinuing after  death,  from  his  own  observation."  He  says  he  was 
called  to  a  woman  in  labour  who  died  about  a  quarter  of  an  hour 
before  his  arrival.  He  was  about  to  perform  the  Caesarean  sec- 
tion, when  he  saw  an  arm  of  the  child  without  the  vulva,  and  to 
which  was  attached  a  string.  This  was  applied  by  the  women 
who  were  present,  and  had  drawn  by  it  so  severely  as  to  fracture 
the  child's  arm.  He  reprimanded  them  severely  for  their  cruelty 
and  ignorance;  and  with  a  view  to  demonstrate  to  them  how 
easily  the  lives  of  mother  and  child  might  have  been  saved,  he 
turned  and  delivered  the  child  without  the  least  diflBculty.  In 
doing  this  he  perceived  the  uterus  to  contract,  in  proportion  as 
the  child  was  withdrawn  as  if  the  woman  were  living.  He  was 
surprised  at  this,  and  introduced  his  hand  into  the  uterus  to  con- 
vince himself  of  the  fact;  he  found  it  contracted  evenly,  and  the 
mouth  of  the  uterus  opposed  the  introduction  of  his  hand.  Doubt- 
ing the  woman  to  be  dead,  he  employed  the  most  active  means 
for  her  recovery,  but  without  success. 

254.  Secondly,  the  uterus  possesses  the  power  of  alternate  ac- 

•  Obser.  sur  les  pertes  de  sang,  Sic.  p.  29.  ob.  xiii. 


OF  THE  ACTION  OP  THE  UTERUS.  105 

tion ;  this  action  manifests  itself  only  when  attempting  to  expel 
something  from  its  cavity;  hut  can  never  do  so,  unless  the  tonic 
contraction  is  in  a  state  of  greater  or  less  perfection.  It  never 
does  take  place,  therefore,  so  long  as  the  uterus  is  in  a  state  of 
atony.  This  contraction  has  also  been  termed  the  spasmodic,  or 
painful  contraction  of  the  uterus;  as,  for  the  most  part,  it  is  ac- 
companied by  pain.  It  is  always  the  effect  of  stimuli,  or  me- 
chanical irritation;  hence  it  appears  during  labour;  during  abor- 
tion ;  or  in  the  form  of  after-pains,  to  expel  coagula,  or  any  other 
foreign  substances,  as  in  dysmenorrhcea.  *  It  is  almost  always 
attended  by  pain,  but  not  necessarily ;  when  pain  attends,  it  is 
not  because  it  is  an  inevitable  consequence  of  contraction,  but 
by  reason  of  some  change  which  the  muscular  fibre  has  undergone 
from  civilization,  refinement,  or  disease.!  We  sec  it  sometimes 
most  efficiently  excited  without  pain,  as  in  the  labours  of  the 
aboriginal  women  of  this  country:  in  the  women  of  Calabria, and, 
among  some,  even  in  this,  our  artificial  state  of  society.  It  tends, 
during  its  best  action,  to  diminish  the  cavity  of  the  uterus,  and, 
consequently,  to  expel  its  contents;  but  its  effects  are  but  tran- 
sitory; the  uterus  returns  to  the  condition  it  was  in  before  this 
contraction  took  place,  and  remains  quiescent,  until  it  is,  by  its 
proper  stimulus,  again  called  into  action — thus  alternating  for  a 
longer  or  shorter  period ;  and  now  constitutes  what  is  usually 
called  "  labour  pains."  This  contraction  is  most  successfully 
exerted  when  all  the  fibres  composing  the  body  and  fundus  of  the 
uterus  act  simultaneously — for  when  it  acts  partially,  it  is  more 
painful  than  when  the  action  is  general,  and  never  achieves  the 
object  it  is  intended  to  effect. 

•  It  must  not  be  supposed  that  the  "labour  pains"  wliich  declare  themselves 
at  the  end  of  nine  montlis  in  cases  of  exti-a-uterine  conceptions,  form  an  excep- 
tion to  this  rule;  for,  in  these  cases,  the  decidua  is  always  produced;  but  at  this 
period  it  becomes  an  extraneous  substance,  and  uterine  contractions  are  esta- 
blished, to  expel  it. 

f  Several  cases  of  such  rapidity  of  labour  have  occui-red  lately,  ;is  to  attract 
the  attention  of  medico-legal  writers  to  the  subject.  A  remarkable  instance 
of  this  kind  has  recently  happened  at  Arras,  in  France.  A  woman,  aged  twenty- 
two  years,  in  the  last  month  of  pregnancy,  was  taken  with  some  pain  in  the 
bowels,  and  thinking  she  was  going  to  have  a  stool,  repaired  to  the  "Garde- 
robe."  It  was  in  the  night.  She  had  scarcely  sat  down  when  her  infant  was 
born  without  any  pain,  or  the  least  notice,  and  it  fell  into  the  privy  below !  She 
knew  nothing  of  what  had  happened,  till  she  heard  the  cries  of  the  child.  It 
was  three  hours  before  it  could  be  Uberated.  It  could  not  be  resuscitated. — 
Lm.  Medico-Chirurg.  Review.  Sept.  1824. 
14 


106  OP  THE  ACTION  OP  THE  UTERUS. 

255.  In  the  brute,  this  contraction  is  successfully  exerted 
without  the  intervention  of  pain  ;  unless  the  labour  be  compli- 
cated with  disease,  or  accident.  When  either  of  these  occur,  the 
same  consequences  follow — namely,  pain.  It  would  be  wrong, 
therefore,  to  suppose,  that  the  labour  of  the  female  brute  is  per- 
formed upon  a  different  principle  from  the  human  female,  be- 
cause she  is  for  the  most  part,  exempt  from  pain — for  truly,  the 
same  general  process  occurs  in  both;  and  in  each,  the  uterus 
exerts  the  same  kind  of  action:  the  only  difference  is,  the  one  is 
performed  with  pain,  and  the  other  without.  It  has  been  sup- 
posed by  some,  from  the  mere  absence  of  pain  in  the  brute,  that 
the  foetus  is  expelled  by  one  uniform,  but  suflSciently  long-con- 
tinued effort,  without  the  intervention  of  the  alternate  contraction ; 
but  this  is  not  so— as  any  one  may  at  once  convince  himself,  by 
observing  the  progress  of  a  labour  in  almost  any  of  our  domestic 
animals.  It  will  be  distinctly,  and  easily  perceived,  that  there 
is  from  time  to  time,  a  suspension  of  uterine  effort,  and  a  repe- 
tition of  it;  marking,  most  conspicuously,  the  intervention  of  the 
alternate  contraction. 

256.  In  the  brute  the  alternate  contraction  is  attended  with 
pain,  when  the  uterus  is  provoked  by  accident  or  disease,  to 
severer  exertion  than  ordinary — and  when  this  happens,  their 
sufferings  are  as  great,  cseteris  paribus,  as  those  of  the  human 
female.  From  this  it  would  appear,  that  such  a  condition  of 
fibre  may  be  accidentally  induced  in  them,  as  is  pretty  perma^ 
nently  fixed  in  the  other.  The  alternate  contraction  would  ap- 
pear to  be  nothing  more  than  a  sudden  and  an  exalted  degree  of 
the  tonic;  and  the  pain  wliich  so  usually  attends  this  action, 
arises  from  some  morbid  or  altered  condition  of  nervous  energy 
in  the  muscular  fibres  composing  the  uterus.  This  would  seem 
to  be  proved  by  the  effects  which  have  followed  civilization  and 
refinement — and  the  consequences  of  domestication  may  be 
traced  in  those  animals  which  participate  with  man  in  his  depar- 
ture from  his  original  simplicity;  for  we  are  informed,  that  the 
artificial  condition  to  which  the  cow,  especially,  is  reduced  by 
domestication,  in  and  near  great  cities,  subjects  her  to  more  dif- 
ficult and  dangerous  labours,  than  those  in  the  natural,  or  less 
artificial  state. 

257.  So  far  as  we  can  determine  the  point,  it  seems,  that  the 
longitudinal  fibres  of  the  body  in  general,  and  those  of  the  uterus 
in  particular,  have  more  especially  felt  the  influence  of  the  causes 


OF  THE  ACTION  OF  THE  UTERUS.  107 

just  mentioned;  for  man  is  said  to  have  lost  much  of  his  original 
vigour  and  strength  ;  and  women  suffer  from  childbearing;  while 
the  circular  muscles  and  sphincters  appear  to  have  lost  nothing 
of  their  primitive  power:  thus  the  heart  and  intestines  have  part- 
ed perhaps  with  none  of  the  original  vigour  with  which  from  the 
beginning  of  the  world,  they  were  endowed;  nor  have  the  seve- 
ral sphincters,  among  which,  the  orifice  of  the  uterus  may  be 
justly  reckoned,  suffered  from  constitutional  abuses. 

258.  In  the  uterus  in  particular,  we  may  observe  pretty  nearly 
the  same  thing — for  I  hold  it  more  than  probable,  that  the  circu- 
lar fibres  of  this  organ  have  not  deteriorated  in  the  same  degree 
as  the  longitudinal,  nor  are  they  subject  precisely  to  the  same 
penalty,  since  they  may  contract  with  great  force,  without  the 
production  of  pain.  We  see  this  well  and  satisfactorily  illus- 
trated in  that  condition  of  the  body  of  the  uterus,  called  the  hour- 
glass contraction.  This  state  may  continue  for  hours,  without 
being  attended  by  pain. 

259.  The  contractions  of  the  uterus  are  entirely  independent 
of  the  will;  their  intervals  can  neither  be  accelerated  nor  retard- 
ed by  any  exertion  of  it;  nor  can  their  force  be  either  augmented 
or  diminished,  by  its  influence;  but  passions  and  emotions  of  the 
mind,  when  strong,  oftentinjes  exert  a  powerful  influence  over  ute- 
rine action — they  may  call  it  into  play,  at  a  time  the  least  expect- 
ed; or  may  suspend  it,  after  it  has  been  strongly  excited.  The 
first  is  proved  by  passions  and  emotions  being  often  followed  by 
abortion;  and  the  latter  by  the  following  fact,  which  fell  under 

my  own  notice: — In  1792,  I  was  called  to  attend  a  Mrs.  C , 

in  consequence  of  her  midwife  being  engaged — as  I  approached 
the  house,  I  was  most  earnestly  solicited  to  hasten  in,  as  not  a 
moment  was  to  be  lost.  I  was  suddenly  shown  into  Mrs.  C.  's 
chamber,  and  my  appearance  there  was  explained,  by  stating  that 
her  midwife  was  engaged.  As  I  entered  the  room,  Mrs.  C.  was 
just  recovering  from  a  pain — and  it  was  the  last  she  had  at  that 
time.  After  waiting  an  hour  in  the  expectation  of  a  return  of 
labour,  I  took  my  leave,  and  was  not  again  summoned  to  her  for 
precisely  two  weeks.  And  Dr.  Lyall  says,  ''  we  have  been  in- 
formed by  a  respectable  practitioner,  of  a  labour  that  had  nearly 
arrived  at  its  apparent  termination,  suspended  for  more  than  two 
days,  in  consequence  of  a  gentleman  having  been  sent  to  the  pa- 
tient, against  whom  she  had  taken  a  prejudice.'"^   Every  accou- 

*  See  Minutes  of  the  medical  evidence  given  in  the  Gardner  Peerage  cause. 


108  OF  PROLAPSUS  FROM  PREGNANCY. 

cheur  has  experienced  a  temporary  suspension  of  pain  upon  his 
first  appearance  in  the  sick  chamberj  but  so  long  a  period  as  two 
weeks,  is  very  rare. 


CHAPTER  IX. 

OF  DISPLACEMENTS  OF  THE  UTERUS. 

260.  Notwithstanding  the  uterus  has  four  ligaments,  purport- 
ing to  support  and  sustain  it  in  situ;  yet  this  is  so  ill  performed, 
as  to  render  it  very  doubtful,  whether  such  was  the  express  in- 
tention of  nature  in  their  formation — certain  it  is,  the  uterus  is 
subject  to  the  impulses  of  the  abdominal  viscera;  to  the  pressure 
of  the  distended  bladder;  and  to  the  influence  of  the  loaded  rec- 
tum and  sigmoid  flexion  of  the  colon;  and  we  may  add,  to  the 
consequences  of  its  own  internal  weight  after  conception. 

Sect.  I. — Of  Prolapsus  from  Pregnancy. 

261.  The  latter  of  the  causes  just  enumerated,  (260)  very 
often  sink  the  uterus  so  low  in  the  pelvis,  as  to  make  it  com- 
pletely occupy  the  vagina;  and  it  sometimes  discovers  even  a 
disposition  to  escape  from  the  os  externum — this  subjects  the 
woman  when  excessive,  to  certain  inconveniences;  but  to  none 
when  moderate ;  except,  perhaps,  a  sensation,  as  if  something 
were  escaping  from  the  vagina,  when  she  is  in  an  erect  posture; 
but  this  is  almost  instantly  relieved,  when  she  disposes  herself  in 
a  horizontal  position.  When  more  excessive,  it  creates  embar- 
rassments to  the  flow  of  urine,  and  the  discharge  of  faeces.  These 
inconveniences  rarely  require  medical  interference;  as  they  are 
relieved  after  a  short  time,  when  the  uterus  acquires  a  sufiicient 
bulk  to  rise  out  of  the  brim  of  the  pelvis.  When  interference 
is  required,  the  application  of  a  proper  pessary  is  all  that  is  ne- 
cessary. 

262.  I  recollect  distinctly  but  two  instances,  in  which  it  was 
necessary  to  introduce  the  catheter — for  the  woman  is  easily  in- 
structed to  lie  upon  her  back  with  her  hips  a  little  elevated  when 
she  is  importuned  to  pass  her  urine;  or  readily  taught  to  press 


RETROVERSION  OP  THE  UTERUS.  109 

back  the  uterus  with  her  finger,  should  this  not  succeed;  or  to  go 
upon  her  knees,  which  has,  in  several  instances,  been  all  that  was 
necessary. 

263.  It  is,  however,  liable  to  some  other  derangements,  which 
are  much  more  difficult  to  remove,  and  much  more  serious  in 
their  consequences;  these  are  the  retroversion  and  anteversion, 
as  well  as  the  prolapsus,  when  pregnancy  has  no  agency  in  it. 

Sect.  II. — Retroversion  of  the  Uterus. 

264.  The  retroversion  is  that  displacement  of  the  uterus,  in 
which  the  fundus  is  precipitated  backwards,  and  places  itself 
between  the  rectum  and  bladder  in  such  a  manner  as  to  be  readily 
felt  upon  the  introduction  of  the  finger  into  the  vagina,  while  the 
neck  is  mounted  up,  behind  the  symphysis  pubis. 

265.  This  situation  of  the  uterus  was  not  distinctly  known, 
until  Dr.  W.  Hunter,*  in  1754,  favoured  the  world  with  an  ac- 
count of  it,  accompanied  by  accurate  drawings  of  the  parts. 
Since  that  period,  this  disease  has  claimed  much  attention,  and 
is  now  perfectly  well  understood.  It  is  not,  however,  regarded 
of  equal  consequence  by  all;  while  Hunter,  Baudelocque,  Mey- 
grier.  Burns,  &c.  look  upon  it  as  an  accident  of  serious  moment; 
others,  as  Denman  and  Merriman,  view  it  almost  with  careless 
indifference — as  both  cannot  be  right,  we  shall,  in  the  prosecu- 
tion of  this  subject,  attempt  to  show  which  of  the  opinions  has  in 
our  estimation,  the  strongest  claims  to  confidence. 

266.  This  deranged  situation  of  the  uterus  may  take  place  in 
its  unimpregnated,  as  well  as  in  its  impregnated  state — the  latter 
is,  however,  by  far  the  more  common.  It  usually  takes  place 
between  the  second  and  the  fourth  month  of  pregnancy,  as  after 
the  latter  period,  the  length  and  thickness  of  the  uterus  will  ex- 
ceed the  opening  of  the  superior  strait,  and  prevent  its  folding 
down  upon  itself.     (See  199.) 

267.  The  remote  cause  of  this  complaint  is,  whatever  tends 
to  depress  the  fundus ;  and  may  be  external  violence,  such  as 
blows,  pressure,  sudden  exertion,  &c.  or  violent  efforts  to  vomit, 
violent  coughing,  an  over  distended  bladder;  or  perhaps,  an  un- 
usual accumulation  of  faeces  in  the  rectum,  or  sigmoid  flexion  of 
the  colon.     These  causes  may  operate  suddenly,  so  as  instantly 

•  Med.  Obs.  Vols.  IV.  &  V. 


110  RETROVERSION  OF  THE  UTERUS. 

to  produce  the  disease;  or  slowly,  requiring  a  long  time  for  its 
completion. 

268.  The  symptoms  produced  by  this  unnatural  situation  of 
the  uterus,  may  be  more  or  less  violent,  according  to  the  size  it 
may  have  acquired;  or  as  the  displacement  may  have  been  sud- 
denly or  slowly  produced.  When  suddenly  induced,  the  symp- 
toms are  usually  violent  and  alarming — such  as  an  immediate 
interruption  to  the  flow  of  urine,  or  permitting  it  to  pass  with 
great  difficulty;  or  to  the  passage  of  the  faeces;  alternate  pains, 
accompanied  by  great  forcing  or  bearing  down;  a  disposition  to 
faint,  &c.  When  considerable  time  is  spent  in  completing  this 
displacement,  the  evils  arising  from  it  are  less  urgent  and  severe. 
But  in  both  cases,  if  the  uterus  be  not  restored,  the  symptoms 
increase  in  intensity;  and  instead  of  a  difficulty,  and  frequent  in- 
clination to  make  water,  there  will  be  a  total  suppression  of  it, 
accompanied  by  a  painfully  intense  desire  to  do  so — for  the 
fostus  goes  on  to  increase  in  size,  arid  the  uterus  to  develope  it- 
self; thus,  giving  additional  pressure,  to  the  parts  with  which  it 
is  in  contact. 

269.  In  the  unimpregnated  state  of  the  uterus,  the  symptoms, 
so  far  as  I  have  observed,  are  never  so  distressing;  the  reason  for 
this  will  be  easily  comprehended;  but  the  parts  do  not  become 
entirely  reconciled  to  their  new  situation.  In  the  impregnated 
state,  however,  so  much  restraint  is  not  imposed  upon  the  uterus, 
as  to  prevent  its  farther  developement,  as  we  have  already  stated ; 
but  the  effects  of  this  increase  can  most  readily  be  anticipated. 
Experience  has  abundantly  shown  that,  if  it  be  not  restored,  it 
will  go  on  to  augment,  so  as  at  last  to  completely  occupy  the 
cavity  of  the  pelvis.*  This  distinctly  points  out  the  time  for  the 
restoration  of  the  fundus  uteri. 

270.  The  symptoms  I  have  enumerated  may,  however,  pro- 
ceed from  other  causes;  it  will,  therefore,  be  proper  to  ascertain 
by  the  touch  the  situation  of  the  uterus,  so  soon  as  symptoms 
become  urgent.  If  retroversion  have  taken  place,  a  roundish  tu- 
mour is  felt  at  the  posterior  and  inferior  part  of  the  lower  strait, 
occupying  more  or  less  room,  as  the  uterus  may  be  a  longer  or 
shorter  time  impregnated,  or  as  it  may  have  been  a  longer  or 
shorter  time  displaced.  The  flnger  cannot  touch  the  projection 
of  the  sacrum;  but  may  gain  a  passage  to  the  upper  strait,  imme- 

»  See  Dr.  Hunter's  case,  Med.  Obb.  and  Inq.;  also,  Wilmer's  cases,  p.  144. 


RETROVERSION  OF  THE  UTERUS.  Ill 

diately  behind  the  symphysis  pubis,  where,  if  the  neck  has  not 
mounted  too  high,  the  os  tincffi  may  be  felt. 

271.  This  disease  may  be  mistaken  for  a  prolapsus  uteri;  but 
can  most  easily  be  distinguished  from  it:  1st.  In  the  retrover- 
sion, by  the  vagina  interposing  between  the  finger  and  the  tu- 
mour; and  the  neck  of  the  uterus  being  mounted  up  behind  the 
symphysis  pubis.  2d.  By  the  absence  of  the  neck  of  the  uterus 
at  this  part,  which  is  always  found  in  advance  of  the  body  and 
fundus  in  a  prolapsus.  3d.  To  the  symptoms  never  being  so  ex- 
treme'in  the  latter.  4th.  By  the  prolapsed  uterus  always  being 
movable,  whereas  in  the  retroversion, ''it  is  obstinately  fixed.  It 
may  also,  according  to  Mr.  Burns,  be  confounded  with  a  diseased 
ovarium,  whence  it  may  chance  to'occupy  this  place,  or  with  an 
extra-uterine  conception,  when  it  may  have  placed  itself  between 
the  rectum  and  vagina,  these  two  complaints,  be  distinguished  by 
noticing,  that  in  both  the  diseased  ovarium  and  the  extra-uterine 
conception,  the  neck  of  the  uterus  is  always  within  reach  of  the 
finger;  and  also  that  a  long  catheter  may  be  readily  passed  in  the 
natural  axis  of  the  uterus;  for  I  believe  the  fundus  would  not  be 
carried  down  with  either  of  these  bodies. 

272.  I  may  moreover  observe,  that  both  ovarial  tumours  and 
extra-uterine  conceptions  are  of  slow  and  regular  progress ;  espe- 
cially, perhaps,  the  latter;  therefore,  should  it  produce  symp- 
toms analogous  to  retroversion,  they  would  be  of  very  gradual 
increase;  and  would  require  a  long  time  for  the  symptoms  to 
become  imperative. 

273.  Dr.  Denman  has  well  described  the  mechanism  of  this 
accident;  but  we  cannot  agree  with  him  entirely  as  to  its  cause; 
he  considers  that  a  distended  bladder  is  always  the  immediate 
cause  of  retroversion,  and  that  a  suppression  of  urine  is  absolute 
only  before,  or  during  the  act  of  retroverting;  therefore,  a  stop- 
page of  the  water  is  the  cause,  and  not  the  consequence  of  this 
complaint,  as  we  have  declared  it  to  be.  (268.)  We  cannot  sub- 
scribe to  this  doctrine ;  and  for  the  following  reasons:  1st.  Be- 
cause we  are  certain  that  it  has  been  suddenly  produced  by  vio- 
lence,''and  without  the  intervention  of  a  suppresion  of  urine. 
Baudelocque  also  declares  the  same  thing.  2d.  Because,  Baude- 
locque  demonstrated  to  his  class  a  slow  retroversion,  which  lasted 
three  or  four  weeks  before  it  v/as  complete;  in  this  case,  there  is 
no  mention  of  any  difficult)^  in  making  water. 

274.  Dr.  Denman  declares,  also,  that  "  the  uterus  must  be  ele- 


112  RETROVERSION  OF  THE  UTERUS. 

vated  before  it  can  be  retro  verted."  To  disprove  this,  it  is  only- 
necessary  to  recur  to  those  cases  which  have  been  suddenly  in- 
duced, as  I  myself  have  witnessed,  from  external  violences: 
though  I  admit  that  the  elevation  of  the  uterus  would  render  it  more 
easy  of  retroversion,  were  the  remote  causes  acting  at  the  same 
time.  For  were  the  elevation  of  the  uterus  essential  to  its  becoming 
retroverted,  how  should  it  ever  take  place  in  the  unimpregnated 
state?  a  circumstance  I  have  more  than  once  seen.  In  one  in- 
stance to  which  I  was  called,  the  patient  had  been  delivered  but 
a  few  weeks.  In  this  case  the  symptoms  were  very  distressing, 
as  was  witnessed  by  my  friend  Dr.  Parrish ;  nor  were  they  re- 
lieved, until  the  uterus  was  restored  by  manual  exertion. 

275.  The  diagnosis  of  this  complaint,  as  given  by  Dr.  Den- 
man,  will  readily  lead  to  the  explanation  of  his  considering  this 
a  trifling  disease;  for,  he  says,  "If  a  woman,  about  the  third 
month  of  pregnancy,  has  a  suppression  of  urine  continuing  a  cer- 
tain  length  of  time,  and  producing  a  certain  degree  of  distention 
of  the  bladder,  we  may  be  assured  that  the  uterus  is  retroverted." 
Should  a  mere  suppression  of  urine  in  a  pregnant  woman,  really 
indicate  a  retroversion,  as  is  declared  by  this  gentleman,  w^e  can 
readily  account  for  his  indifference  to  its  consequences,  and  his 
trusting  its  cure  to  nature,  or  the  occasional  drawing  off  the  water 
by  the  catheter.  The  young  practitioner  is  forewarned  against 
this  uncertain  plan ;  he  is  to  look  upon  this  complaint  as  one  of 
eventual,  if  not  of  immediate  danger;  especially,  when  the  tem- 
porizing plan  we  shall  now  speak  of,  does  not  succeed. 

276.  As  the  most  pressing  symptom  in  retroversion  is  the  in- 
terruption of  the  urine,  we  should  most  sedulously  endeavour  to 
prevent  its  continuing  too  long ;  and  the  consequences  should  be 
candidly  stated  to  the  woman,  should  she  permit  her  delicacy  to 
interrupt  an  essential  point  of  duty.  The  catheter  should  be  em- 
ployed pro  re  nata ;  and  the  bowels  emptied  daily,  either  by 
medicine  of  a  mild  kind,  or  by  injections;  if  this  plan  do  not 
succeed  in  restoring  the  fundus,  we  should  then  maturely  con- 
sider the  propriety  of  replacing  it  mechanically.  To  aid  our 
judgment,  we  should  consider ;  first,  the  period  of  gestation  ; 
secondly,  the  degree  of  dcvelopement  of  the  uterus:  thirdly,  the 
nature  or  severity  of  existing  symptoms.  The  period  of  gesta- 
tion should  almost  always  influence  our  conduct  in  this  com- 
plaint; and  we  may  lay  it  down  as  a  general  rule,  the  nearer 
that  period  approaches  four  months,  the  greater  will  be  the  ne- 


RETROVERSION  OF  THE  UTERUS.  113 

cessity  for  acting  promptly  to  procure  the  restoration  of  the  fun- 
dus ;  the  reason  for  this  is  obvious  ;  every  day  after  this  will  but 
increase  the  difficulty  of  restoration,  as  the  ovum  is  continually 
augmenting  in  size.  The  degree  of  developement  should  also  be 
taken  into  consideration;  for  one  uterus  may  be  as  much  expand- 
ed at  three  months,  as  another  is  at  four;  consequently,  if  this 
obtain,  there  is  a  decided  reason  for  acting  earlier,  than  may  at 
other  times  be  necessary;  so  also  at  the  fourth  month,  if  the  de- 
velopement be  less  than  is  usual  for  that  period,  we  may,  every- 
thing being  equal,  delay  the  attempt  at  reposition,  if  any  reason 
present  itself  to  make  this  eligible.  The  extent  or  severity  of 
symptoms  must  ever  be  kept  in  view;  for  instance,  we  must 
not  temporize  too  long  where  the  suppression  of  urine  is  com- 
plete, and  cannot  be  relieved  by  the  catheter;  lest  the  bladder 
become  inflamed,*  or  gangrenous,!  or  burst.  J  For  the  bladder, 
from  its  very  organization,  cannot  bear  distention  beyond  a  cer- 
tain degree,  or  beyond  a  certain  time,  without  suffering  serious 
mischief. 

277.  From  this  I  conclude,  that  the  uterus  should  in  every  in- 
stance be  restored  when  practicable,  at,  or  very  little  after,  the 
fourth  month  at  farthest;  for,  if  left  longer  than  this,  the  chance 
of  succeeding  is  every  day  diminished;  and  I  am  firmly  of  opi- 
nion, that  nothing  can  justify  longer  delay  at  this  time;  more 
especially,  if  it  proceed  from  the  vain  hope,  that  nature  will  re- 
lieve herself  at  the  full  period  of  gestation.§ 

•  Dr.  Bell,  Med.  Facts,  Vol.  III.  p.  32.   f  Mi-.  Lynn,  Med.  Obs.  Vol.  V.  p.  388. 

+  Dr.  Squire,  Med.  Review  for  1801. 

§  It  is  with  both  surprise  and  regret,  that  I  observe  m3self  charged  with  a 
want  of  precision  in  tlie  treatment  of  this  complaint,  No.  III.  Vol.  IV.  third 
series  of  the  New  England  Journal,  &c.  After  having  quoted  at  length  the 
whole  of  paragraphs  276  and  277,  the  writer  says,  "  we  have  thought  much  of 
this  matter,  and  still  do  not  feel  satisfied  with  the  course  prescribed  by  Dr.  D. 
in  this  quotation.  We  may  have  expressed  ourselves  too  strongly,  in  saying 
the  '  course  prescribed'  by  the  author.  His  language  is  not  very  precise,  and 
tve  understand  him  as  saying  and  teaching,  that  attempts  to  reduce  the  displaced 
organ  need  not  be  made  before  the  fourth,  or  at  a  very  httle  after  the  fourth 
month.  This  to  us  is  not  sound  doctrine."  Nor  is  it  to  me ;  nor  have  I  said, 
or  ever  taught,  such  a  doctrine.  And  it  is  unfeignedly  a  matter  of  wonder  that 
such  a  construction  could  have  been  given  to  what  I  have  advanced  in  the  two 
paragraphs  just  indicated.  For,  through  the  whole  of  my  direction.s,  I  have 
aimed  at  precision ;  and,  in  par.  277,  I  expressly  deprecate  a  delay  beyond 
the  fourth  month;  and  distinctly  recommend  the  attempt  at  reduction  without 
regard  to  the  period  of  gestation,  wherever  symptoms  become  pressing ;  but 
15 


114  RETROVERSION  OF  THE  UTERUS. 

278.  The  symptoms  I  have  noticed  above,  should  teach  us  the 
propriety  and  necessity,  of  ascertaining  the  true  situation  of  the 
uterus,  by  an  examination  per  vaginam;  and  until  this  be  done, 
though  we  may  be  disposed  to  hint  our  suspicions,  we  should 
never  positively  affirm,  that  the  patient  is  labouring  under  retro- 
version. For  I  have  frequently  prescribed  a  little  sweet  nitre  and 
laudanum  for  a  difficulty  of  passing  water  in  pregnant  women, 
with  the  most  decided  success;  and  when  these  symptoms  were 
more  severe  or  obstinate  than  common,  I  have  examined  per 
vaginam,  and  sometimes  without  finding  the  uterus  in  a  state  of 
retroversion. 

279.  My  experience  has  furnished  me  with  few  facts  of  which 
I  am  more  certain,  than  that  ''a  certain  degree  of  distention  of 
the  bladder"  may  exist,  and  for  a  considerable  time,  without  i^ro- 
ducing  retroversion;  even  where  I  have  been  under  the  necessity 
of  using  the  catheter.  And  I  am  also  certain,  in  retroversion, 
that  the  mere  removal  of  the  urine  will  but  rarely,  nay,  not  once 
perhaps  in  ten  times,  be  sufficient  to  ensure  the  spontaneous 
restoration  of  the  fundus,  where  the  complaint  is  of  long  standing, 
or  the  pregnancy  advanced  beyond  the  third  month.  But  let  me 
be  clearly  understood  to  mean,  that  the  precaution  of  drawing 
off  the  water  when  practicable,  and  that  as  frequently  as  the 
exigencies  of  the  case  demand,  is  indispensable,  either  to  the 
spontaneous  or  artificial  reposition  of  the  uterus. 

280.  I  have  great  reason  to  believe,  that  an  exclusive  reliance 
upon  drawing  off  the  water,  has  been  productive  of  the  most 
serious  evils,  if  not  of  death  itself  in  some  cases:  it,  therefore, 
should  never  be  exclusively  trusted  to,  except  at  the  early  period 
of  gestation.    If  the  woman  approach,  or  if  she  exceed  the  fourth 

until  then,  I  am  every  way  willing  to  temporize,  as  restoration  sometimes  takes 
place  spontaneously;  but  I  believe  we  lose  nothing  by  delay  up  to  the  period 
pointed  out,  where  the  condition  of  tlie  bladder  does  not  form  tlie  principal  in- 
dication. 

From  what  I  liave  seen  of  this  complaint,  I  am  disposed  to  tliink,  that  the 
reviewer  will  alter  his  opinions,  when  he  has  witnessed  more  cases  than  he  pro- 
bably has  up  to  this  time.  I  view  the  complaint  in  as  serious  a  light  as  he  pos- 
sibly can;  indeed  I  am  charged  by  some  witli  having  minecessary  fears,  and  of 
recommending  interference,  when  it  is  not  called  for  ;  it  will  therefore  be  seen 
that,  on  the  one  hand,  I  am  accused  with  too  much  indifference  to  tlie  ti-eatment 
of  tliis  complaint ;  and  on  the  oUier  with  absolute  temerity.  I  shall  not,  how- 
ever, feel  myself  guilty  of  either,  until  future  experience  proves  my  present 
viewst  0  be  wrong.    , 


RETROVERSION  OP  THE  UTERUS,  115 

month,  the  attempt  at  restoration  should  most  unquestionably  be 
made;  nor  should  it  be  abandoned,  but  for  very  strong  reasons; 
nothing,  indeed,  but  the  impossibility  of  succeeding,  should  in- 
duce us  to  leave  the  patient  to  her  fate — I  say,  to  her  fate;  for, 
what  can  we  promise  ourselves  in  her  favour?* 

281.  The  objections  usually  urged  against  the  attempt  to  re- 
place the  fundus,  are:  1st.  The  hazard  of  provoking  abortion. 
2d.  That  it  does  not  always  succeed,  after  strong  and  repeated 
efforts. 

282.  With  respect  to  the  first,  there  is  abundant  proof  in  my 
own  experience,  as  well  as  that  of  others,t  that  abortion  is  not  a 
necessary,  though  it  may  be  a  possible  consequence  of  the  at- 
tempt. I  have  never  seen  it  follow:  therefore  the  fear  of  an 
imaginary  evil,  must  not  induce  us  to  subject  our  patient  to  a 
serious  and  positive  harm.  The  risk  of  abortion  is  but  trifling; 
but  the  neglect  of  reposition  at  the  proper  time,  is  a  very  serious 
piece  of  mismanagement. 

283.  As  regards  the  second,  if  it  fail,  it  must  generally  be  at- 
tributed to  our  neglecting  the  proper  moment  for  acting;  or, 
when  it  has  not  been  properly  performed.  Having  decided  upon 
the  propriety  and  necessity  of  giving  aid  to  the  suffering  woman, 
I  shall  next  give  directions  for  the  best  mode  of  performing  this, 
I  must  first  consider  what  forces  are  operating  to  prevent  the  res- 
toration of  the  fundus,  before  I  describe  how  they  are  to  be  over- 
come: they  will  be  found  to  be;  1st.  A  distended  bladder.  2d. 
An  impacted  rectum;  and  most  probably,  a  loaded  colon  at  its 
sigmoid  flexure.  3d.  The  counteracting  efibrts  of  the  woman 
herself.     4th.  The  too  great  bulk  of  the  uterus. 

284.  The  first  thing  to  be  accomplished  is,  the  evacuation  of 
the  urine  by  the  catheter;  in  this,  it  is  said,  we  cannot  always 
succeed.  I  have  never  met  with  such  a  case;  and  Mr.  Burns  de- 
clares the  same  thing;  na)^,  he  even  goes  farthei' — he  says  he 
does  not  believe  it  can  occur — it  must,  therefore,  be  very  rare.| 
Dr.  Den  man  has  some  very  useful  remarks  upon  this  subject, 
which  I  would  recommend  to  be  studied — he  advises  the  em- 
ployment of  the  flexible  male  catheter;  in  this  I  heartily  concur; 

*  Mei-riman.  f  See  Baudelocque,  Hunter,  Wall,  Meygrier,  &c. 

:t:  Since  the  above  was  written,  a  case  under  the  care  of  my  friend  Dr.  Jack- 
son, and  myself,  has  occurred — in  this  case  it  was  impossible  for  several  hours  to 
pass  the  catheter.  By  leeching,  and  injections,  however,  this  difficulty  was 
eventually  overcome,  and  the  uterus  restored  itsdf  in  due  time. 


116  RETROVERSION  OF  THE  UTERUS. 

he  also  cautions  against  any  attempt  to  display  dexterity,  by  the 
quick  introduction  of  this  instrument;  and  recommends  the  slow 
and  cautious  use  of  it — he  also  proposes  pressure  upon  the  abdo- 
men, to  promote  the  discharge  of  the  urine;  I  may,  however, 
add,  that  not  only  the  introduction  of  the  catheter  should  be  slow, 
but  the  drawing  off  the  water  also — I  am  certain  I  once  saw 
serious  mischief  arise  from  inattention  to  this  direction. 

285.  To  overcome  the  second  difficulty,  injections  should  be 
thrown  up  the  rectum  if  practicable;  but  which,  it  must  be  con- 
fessed, is  sometimes  impossible — we  can  succeed,  however,  with 
the  elastic  gum  catheter  of  a  large  size,  when  the  common  means 
have  failed;  the  injection  should  consist  simply  of  a  table-spoon- 
ful of  common  salt  and  a  pint  of  water.  A  few  hours  before 
we  attempt  the  reduction,  small  but  repeated  doses  of  the  sul- 
phate of  magnesia  may  be  given;  provided  the  stomach  is  not 
distressed  by  vomiting,  or  severe  nausea. 

286.  The  third  difficulty  which  may  oppose  us,  is  the  violent 
and  involuntary  efforts  to  bear  down,  to  which  the  woman  is  ex- 
cited, by  the  presence  of  the  hand  within  the  vagina — this  is 
decidedly  the  greatest  trouble  we  meet  with  in  ordinary  cases — 
for  we  may  be  foiled  in  our  attempts  at  reposition,  though  the 
emptying  of  the  bladder  and  rectum  should  not  have  been  found 
troublesome.  To  overcome  this  opposition,  experience  has  re- 
peatedly taught  me  the  efficacy  of  bleeding  to  fainting,  or  near 
to  it. 

287.  When  we  have  determined  upon  the  bleeding,  we  should 
be  prepared  beforehand,  to  take  advantage  of  the  deliquium, 
as  its  continuance  is  transitory — the  bed  should  be  prepared 
in  such  a  manner,  as  will  allow  the  patient  to  lie  upon  her  back, 
with  the  perinseum  free  from  the  edge  of  the  bedstead,  and  her 
shoulders  a  little  depressed — some  protection  should  be  placed 
between  the  back  of  the  woman  and  edge  of  the  bedstead,  that 
she  may  receive  no  injury  from  its  hardness — the  parts  should  be 
well  lubricated  with  hog's  lard,  oil,  or  a  strong  mucilage  of  flax- 
seed— a  chair  should  be  placed  for  each  foot  to  rest  upon,  and 
these  supported  by  two  assistants.  The  position  is  the  same,  as 
recommended  for  "turning,"  &c.* 

288.  When  everything  is  in  readiness,  the  arm  should  be  tied 
up,  and  the  patient  made  to  stand  near  the  bed;  a  large  orifice 

*  See  Chap.  XVIU.  Sect.  1. 


RETROVERSION  OP  THE  UTERUS.  117 

must  be  made,  and  blood  drawn  until  faintnessis  induced — when 
this  happens,  the  arm  can  be  secured,  and  the  woman  placed  as 
just  directed— the  hand,  after  being  well  lubricated,  should  be 
passed  into  the  vagina,  in  a  state  of  supination;  the  fingers  re- 
tracted in  such  a  manner,  as  to  form  a  straight  line  at  their  ex- 
tremities; they  must  then  be  gently  pressed  against  the  base,  as 
it  were  of  the  tumour  found  within  the  vagina,  so  as  to  move  it 
backwards  and  upwards  along  the  hollow  of  the  sacrum,  until  the 
mass  shall  reach  above  the  projection  of  this  bone;  when  thus 
far,  the  hand  may  be  withdrawn;  and  a  pessary  be  introduced  of 
a  proper  size:  the  woman  must  remain  quiet  in  bed  for  three  or 
four  days,  the  urine  for  this  period  should  be  drawn  off  as  often 
as  may  be  required;  and  the  faces  evacuated  by  injections. 

2S9.  The  last  of  our  embarrassments  arises  from  the  size  of  the 
uterus  being  equal  to,  or  greater  than  the  opening  of  the  superior 
strait;  this  will  be  confessed  to  be  one  of  much  moment  and  in- 
terest— yet,  I  trust,  it  is  not  beyond  remedy — I  believe  that  the 
plan  just  suggested,  might  succeed  even  here:  but  I  confess  it 
wants  the  test  of  experience.  It  should  from  every  consideration 
be  tried  before  severer  means  be  adopted;  for  if  it  fail,  we  lose 
nothing.  But  suppose  it  fail,  what  is  to  be  done?  Three  modes 
of  operating  present  themselves  in  this  dilemma. 

290.  First,  to  confide  entirely  in  the  resources  of  nature,  as 
recommended  by  Dr.  Merriman. 

291.  Second,  to  attempt  to  provoke  abortion,  by  rupturing  the 
membranes,  through  the  os  tineas. 

292.  Third,  to  puncture  the  uterus  through  the  rectum,  as  ad- 
vised by  Dr.  Hunter,  or  through  the  vagina,  as  practised  by  M. 
Jourel. 

293.  With  respect  to  the  fa-st,  there  is,  from  all  I  can  learn, 
but  little  temptation  to  trust  to  it.  See  strictures  on  Dr.  Merri- 
man's  opinions,  in  "  Essays  on  various  Subjects  connected  with 
Midwifery,"  by  the  author,  p.  291. 

294.  The  second,  if  practicable,  would  unquestionably  be  the 
mildest  and  safest;  but  its  success,  (so  far  as  I  can  at  present  de- 
termine,) must  be  very  uncertain,  or,  it  may  be  always  impracti- 
cable,* 

295.  The  third  alternative  has  been  condemned  by  some  of 
the  British  writers;  but,  as  it  would  appear,   without  sufficient 

*  See  Essays  on  various  Subjects,  &c.  by  W.  P.  Dewees,  p.  287. 


lis  OP  THE  OBLIQUITIES  OF  THE  UTERUS, 

reason;  since  M.  Jourel  succeeded  recently  in  a  case,  the  details 
of  which  are  highly  interesting  and  instructive,  and  should  be 
carefully  consulted  by  all  who  practise  midwifery.*  We  find 
also  in  the  Ed.  Med.  and  Surg.  Journal,  for  April,  1830,  that  this 
operation  has  also  been  performed  with  success,  by  Mr.  Beynham. 

296.  In  the  anteversion,  the  fundus  of  the  uterus  is  thrown 
forward,  and  downward ;  so  that  it  presses  immediately  against 
the  posterior  and  inferior  portion  of  the  bladder,  while  its  neck  is 
carried  backward  towards  the  projection  of  the  sacrum.  In  this 
displacement,  the  symptoms  are  said  to  be  less  severe,  than  with 
the  retroversion — the  tumour  being  anterior,  and  the  neck  of 
the  uterus  posterior,  will  readily  distinguish  the  one  from  the 
other — I  have  never  seen  a  case  of  this  kind  so  strongly  marked 
as  to  leave  no  doubts  of  its  existence — I  was  once  called  to  a  pa- 
tient in  whom  I  suspected  it  had  taken  place ;  but  it  was  in  a  par- 
tial degree,  if  at  all — the  symptoms  were  distressing,  but  eventu- 
ally relieved  by  the  use  of  the  catheter,  and  anodyne  injections. 
This  disease  has  been  mistaken  for  stone  in  the  bladder,  agreea- 
bly to  Luret,t  and  the  operation  of  lithotomy  absolutely  per- 
formed. 

297.  When  the  unimpregnated  uterus  is  retroverted,  it  creates 
fewer  inconveniences  than  when  impregnated — the  indications  are 
precisely  the  same — the  mode  of  reduction  is  also  similar.  This 
can  sometimes,  however,  be  effected  without  the  introduction  of 
the  hand,  by  the  proper  application  of  the  fingers  alone — I  suc- 
ceeded in  this  way,  in  two  instances  of  this  kind  of  retroversion; 
both  of  which,  however,  were  very  recent  when  the  attempt  was 
made. 

Sect.  III. — Of  the  Obliquities  of  the  Uterus. 

298.  The  inconveniences  arising  from  these  species  of  dis- 
placement of  the  uterus,  are  sufficiently  serious  to  merit  an  expo- 
sition of  their  mechanism.  When  we  consider  the  globe-like  form 
that  the  uterus  constantly  maintains  during  the  progress  of  its  de- 
velopement;  when  we  recollect  how  feebly  it  is  supported  by 
its  ligaments;  and  bring  to  mind  the  angle  at  which  it  must  pass 
through  the  superior  strait,  we  shall  not  be  at  all  surprised  to 
find  it  fail  to  maintain  such  a  situation  in  the  abdomen,  as  will 

*  Dictionnaire  des  Sciences  Medicales,  Vol.  IX.  p.  31. 
t  Jour,  de  Med.  Vol.  IV.  *% 


OP  THE  OBLIQUITIES  OP  THE  UTERUS.  119 

enable  the  axis  of  its  fundus,  and  that  of  the  superior  opening  of 
the  pelvis  to  coincide.  If  we  add  to  this,  the  peculiarity  of 
conformation  of  several  of  the  parts  of  the  pelvis,  and  of  its 
more  immediate  dependencies ;  and  the  influence  these  have 
upon  this  organ  during  its  ascent  into  the  abdomen,  we  shall 
soon  be  convinced  of  almost  the  impossibility  of  its  centre  pre- 
serving a  correspondence  with  that  of  the  pelvis — hence  the 
constant  presence  of  obliquity  in  one  form  or  other,  in  almost 
every  pregnancy. 

299.  The  obliquities  of  the  uterus  may  be  divided  into  three 
kinds : — 1st.  The  right  lateral  obliquity ;  2d.  The  anterior  obli- 
quity ;  3d.  The  left  lateral  obliquity.*  In  the  first,  the  fundus 
of  the  uterus  is  found  more  or  less  inclined  to  the  right  por- 
tion of  the  abdomen,  and  its  length  and  departure  from  a  vertical 
line  can  readily  be  detected  by  the  hand  placed  upon  it — and 
when  this  inclination  is  excessive,  as  it  sometimes  is,  it  may  be 
observed  by  the  eye,  especially  if  the  woman  be  viewed  from  be- 
hind. This  species  is  by  far  the  most  frequent ;  owing  to  the 
constant  presence  and  influence  of  certain  determining  causes: 
1st.  The  manner  in  which  the  rectum  descends  in  the  hollow  of 
the  sacrum;  the  rectum,  in  passing  into  the  pelvis,  does  not  pre- 
serve the  centre  of  this  bone,  but  inclines  rather  to  the  left  por- 
tion of  itj  of  course,  when  filled  with  faeces,  it  will  occupy  apart 
of  the  lower  strait;  and  consequently,  will  give  an  inclination  to 
the  uterus  towards  the  right  side;  2d.  The  sigmoid  flexion  of  the 
colon,  from  its  position,  and  almost  constant  distention,  will  aid 
by  its  impulses  the  already  inclined  fundus,  in  the  same  direction; 
and  if  we  add,  3d.  The  round  projection  ofiered  by  the  salient 
portion  of  the  sacrum,  we  shall  be  at  no  loss  to  determine  why 
the  right  lateral  obliquity  is  of  all  the  most  frequent.  It  would 
not  however  be  correct  to  suppose,  that  the  os  uteri  would  be 
found  always  in  an  exact  line  with  the  fundus — I  have  known  a 
number  of  exceptions  to  this. 

300.  In  the  second,  or  anterior  obliquity,  the  fundus  of  the 
uterus  continues  to  advance  in  the  direction  it  received  when 
passing  through  the  superior  strait — when  treating  on  the  pelvis, 

*  Levret  has  added  a  fourtli — this  consists  of  a  fulluig  of  tlic  womb  back- 
wards upon  the  lumbar  vertebrae;  but  that  tliis  obliquity  may  take  place,  it  is 
necessary  tliat  this  column  be  flexed  outwards — a  deformity  may  give  rise  to 
this  variety  of  obliquity,  but  cannot  happen  without  it,  it  is  therefore  not  neces- 
sary to  notice  fuither. 


120  OP  THE  OBLIQUITIES  OF  THE  UTERUS. 

I  mentioned  that  this  was  at  an  angle  of  between  thirty  and  forty 
degrees;  consequently  the  fundus  would  carry  the  abdominal  pa- 
rietes  before  it  in  all  instances,  were  not  a  counteracting  influence 
found  in  the  firmness  and  elasticity  of  these  parts — therefore,  the 
anterior  obliquity  will  be,  in  frequency  and  extent,  in  exact  pro- 
portion to  the  want  of  resistance  from  these  parietes — hence  it  is 
rare  in  a  first  pregnancy,*  owing  to  the  firmness  of  the  abdominal 
integuments;  and  of  very  frequent  occurrence  in  subsequent 
ones.  Sometimes  the  extent  of  this  obliquity  is  almost  incredi- 
ble, especially  in  small  women  who  are  much  upon  their  feet; 
and  in  those  who  have  a  deformity  of  pelvis.  In  this  obliquity 
there  will  be  more  or  less  correspondence  of  the  axes  of  the 
fundus  and  mouth  of  the  uterus,  as  this  deviation  may  be  more 
or  less  excessive. 

301.  This  obliquity  is  almost  always  a  source  of  great  inconve- 
nience to  the  woman  even  before  labour;  for  after  the  seventh 
month,  the  fundus  is  so  depending,  and  so  much  in  advance,  as 
to  alter  the  usual  centre  of  gravity  ;  and  the  woman  is,  when 
either  walking  or  standing,  obliged  by  constant  exertion,  to  make 
herself  a  new  one.  This  is  accompanied  often,  and  more  espe- 
cially towards  the  latter  period  of  pregnancy,  with  severe  pain  in 
the  back,  loins,  and  hips;  together  with  a  forcing  and  bearing 
down;  urging  the  woman  to  make  water,  or  to  go  to  stool.  I  have 
frequently  known  these  symptoms  so  severe,  as  to  oblige  the 
woman  to  keep  her  bed,  that  she  might  enjoy  a  moment's  respite 
from  their  urgency — this  especially  happens  to  short  women  who 
have  had  a  number  of  children,  and  who  have  always  had  severe 
labours. 

302.  I  have  been  frequently  consulted  for  this  very  unpleasant 
situation  of  the  uterus — but  there  is  but  one  remedy  for  it,  so  far 
as  I  know;  namely,  to  support  the  body  and  fundus,  as  much  as 
may  be,  by  a  proper  bandage,  or  dress — the  most  effectual  I  have 
employed  is,  a  pair  of  drawers,  with  a  waistcoat  attached  to  it 
which  will  lace  behind.  The  waistcoat  need  not  reach  but  a 
little  above  the  umbilicus;  but  it  must  be  maintained  in  its  situa- 
tion by  a  support  from  above  by  a  pair  of  properly  adjusted  sus- 
penders. This  dress  should  be  put  on  in  the  morning  before  the 
woman  rises  upon  her  feet;  and  when  it  is  about  to  be  applied, 

*  It  may  be  proper  to  observe,  I  have  never  seen  it  take  place  in  a  first 
pregnancy.     1  have  seen  one  exception  since  the  above  ^as  written. 


OF  THE  OBLIQUITIES  OP  THE  UTERUS.  121 

the  fundus  must  be  raised,  by  the  hands  of  the  patient  being 
placed  under  it,  and  lifted  as  it  were  upwards;  while  the  back 
part  of  the  waistcoat  is  laced  sufficiently  tight  to  give  support  to 
the  uterus,  when  left  to  itself.  By  this  simple  contrivance,  I 
have  seen  women  become  active,  and  capable  of  attending  to 
their  domestic  concerns,  who,  previously  to  its  application,  were 
confined  to  their  beds. 

303.  The  third,  or  left  lateral  obliquity,  is  so  rare,  as  to  scarce- 
ly merit  a  mention;  and  especially,  as  the  inconveniences  arising 
from  it,  must  be  nearly  the  same  as  from  the  right  lateral;  and 
the  mode  of  remedying  it  also  the  same,  mutatis  mutandis. 

304.  It  is  of  much  practical  importance,  that  these  different 
deviations  be  known,  as  they  are  for  the  most  part,  of  easy  re- 
medy;  but  when  not,  much  suffering  is  experienced.  Thus,  in 
the  right  lateral  obliquity,  placing  the  woman  upon  her  left  side, 
will  very  frequently  be  all  that  is  required;  but  should  this  posi- 
tion not  bring  the  os  uteri  to  the  axis  of  the  pelvis,  we  must  aid 
it  by  the  introduction  of  a  finger  within  it,  when  it  is  either  well 
dilated  or'  easily  dilatable;  and  this,  in  the  absence  of  pain; 
when  hooked,  it  must  be  gently  drawn  towards  the  symphysis 
pubis,  and  retained  tliere,  until  a  pain  ensue ;  should  the  contrac- 
tion of  the  mouth  of  the  uterus  offer  much  opposition  to  the  force 
which  is  to  keep  it  at  the  symphysis,  as  just  mentioned,  we  should 
gradually  yield  to  it;  but  need  not  withdraw  the  finger — when 
relaxation  has  taken  place,  wc  again  conduct  the  os  uteri  to  the 
place  before  indicated:  and  maintain  its  position  there,  unless 
again  forced  to  relax  our  effort  for  the  reason  just  stated — in  this 
manner  we  alternately  retract,  and  relax,  until  we  establish  a 
correspondence  between  the  axes  of  the  fundus,  the  mouth  of 
the  uterus,  and  the  pelvis;  when  this  is  accomplished,  we  will 
find  the  labour  advance  with  more  rapidity,  and  with  less  pain. 

305.  In  the  second,  or  anterior  obliquity,  the  same  indication 
presents  itself;  namely,  to  procure  a  proper  relation  between  the 
axes  of  the  uterus  and  pelvis ;  but  the  mode  of  fulfilling  it  is  differ- 
ent— in  this  case  we  place  the  woman  upon  her  back ;  and,  at 
the  time,  and  under  the  circumstances  pointed  out  above,  (304,) 
we,  with  the  point  of  the  finger,  search  for  the  os  uteri  towards 
the  projection  of  the  sacrum.  In  cases  of  extreme  obliquity,  it  is 
oftentimes  difficult  to  reach  the  os  uteri  by  the  ordinary  mode  of 
examination  ;  when  this  happens,  the  pendulous  belly  should  be 
raised  and  supported  by  an  assistant,  with  a  view  to  depress  the 

16 


122  OF  THE  OBLIQUITIES  OF  THE  UTERUS. 

OS  uteri should  this  not  succeed,  and  should  the  pains  be  brisk, 

the  head  will  be  found  to  sink  lower  and  lower  in  the  pelvis, 
covered  by  the  stretched,  anterior  portion  of  the  uterus.  If  ad- 
vantage be  not  now  taken  to  introduce  the  hand  to  restore  the  os 
uteri  to  the  proper  axis  of  the  pelvis,  much  suffering  must  be 
endured ;  and  much  risk  incurred  by  permitting  the  head  to  de- 
scend, covered  by  the  uterus. 

306.  Whenever  the  os  uteri  cannot  be  reached  by  a  well- 
directed  search  in  the  ordinary  way,  we  must  introduce  the  hand 
well  lubricated,*  so  that  its  palm  may  be  next  to  the  distended 
uterus;  a  finger  should  then  be  made  to  reach  up  to  the  neigh- 
bourhood of  the  projection  of  the  sacrum,  where,  on  some  one 
portion  of  the  uterine  globe,  the  os  uteri  will  be  detected — when 
discovered,  we  should  hook  it  upon  the  point  of  the  finger,  (pro- 
vided it  is  either  dilated,  or  easily  dilatable,)  and  draw  it  towards 
the  centre  of  the  inferior  strait — when  it  has  followed  so  far,  the 
hand  may  Le  gently  withdrawn,  (but  not  the  finger  from  the  os 
uteri,)  and  the  uterus  detained  there,  until  the  proper  direction 
of  the  forces,  and  the  axis  of  the  uterus,  are  in  correspondence. 
By  this  simple  proceeding,  much  time  and  suffering  are  saved; 
and,  in  some  instances,  I  am  well  persuaded  that  much  risk  is 
prevented.  Baudelocque  has  most  satisfactorily  illustrated  the 
advantage  of  judicious  interference,  and  the  consequences  of  the 

*  I  have  seen  with  much  pleasure,  in  the  .Tuly  and  August  Nos.  of  the  Lond. 
Med.  and  Chir.  Review,  a  most  hberal  examination  of  this  work.  But  the  author 
of  the  Review  seems  not  to  have  cleai-ly  understood  this  par.  (306)  as  he  cau- 
tions against  the  introduction  of  tlie  hand,  for  the  purpose  of  rectifying  the  bad  po- 
sition of  the  OS  uteri;  stating,  it  would  be  a  difficult  or  painful  attempt  to  do  so, 
witli  a  first  child.  I  agree,  under  such  a  circumstance,  it  might  be  inconvenient ; 
but  the  obliquity  now  under  consideration,  I  have  never  known  to  take  place  in 
a  first  pregnancy ;  consequently,  tlie  objections  cannot  be  constantly  valid :  yet 
were  it  even  to  happen  in  a  first  laboui-,  I  should  unquestionably  pursue  the  same 
conduct,  from  a  conviction,  that  I  should  expose  my  patient  to  the  lesser  evil. 

Let  me,  however,  be  clearly  understood  to  mean,  tliat  I  would  introduce  the 
hand,  if  the  labour,  from  its  dm-ation  and  force,  gave  me  reason  to  beheve,  that 
the  want  of  progress  of  the  presenting  part,  was  owing  to  the  consti-ained  po- 
sition of  the  uterus ;  and  when  the  os  uteri  cannot  be  reached  by  tlie  orchnaiy 
mode  of  examination ;  consequenth',  wlien  it  did  not  correspond  with  the  axis 
of  the  pelvis.  This  I  confess  to  be  a  situation  of  rare  occirrrence  ;  yet  it  b  one 
to  be  met  with,  as  I  can  testify,  and  it  should  be  provided  for,  if  it  occui":  for, 
if  the  OS  uteri  be  not  within  reach  by  a  common  search,  and  it  shall  give  rise  to 
an  operation  like  the  one  to  be  related  presently,  would  it  not  then  be  more 
than  fastidious,  to  withhold  a  proper  examination,  from  a  mere  repugnance  to 
introduce  the  hand  into  the  vagina,  if  the  labour  were  even  a  first  one  ? 


OP  THE  OBLIQUITIES  OP    THE  UTERUS.  123 

neglect  of  it,  by  the  recital  of  two  apposite  cases,  to  which  I 
would  refer  the  reader  with  much  advantage  to  himself. 

307.  Chapman  also  relates  a  somewhat  similar  case;  that  is, 
labour  was  long  protracted  in  consequence  of  the  very  posterior 
situation  of  the  os  tincse.  He  introduced  his  finger,  drew  it 
forward,  and  established  a  proper  correspondence  between  the 
direction  of  the  uterine  forces  and  the  axis  of  the  os  uteri. 
Chapman,  however,  does  not  appear  to  have  understood  his  own 
case;  he  supposed  the  delay  was  occasioned  by  the  os  uteri  being 
but  little  opened.  He  attempted  its  dilatation  ;  and  this  attempt 
brought  the  opening  of  the  uterus  to  correspond  with  the  axis  of 
the  vagina,  by  which  means  the.  woman  was  speedily  delivered.* 

308.  I  must  take  this  opportunity  to  notice  a  few  remarks 
made  by  Mr.  North  upon  this  point,  in  the  London  Medical  and 
Physical  Journal,  for  September,  1827.  Mr.  North  seems  averse 
from  pursuing  the  plan  I  have  proposed  for  the  relief  of  the  an- 
terior obliquity  of  the  uterus.  He  objects  to  the  plan,  because 
he  has  "known  inflammation  of  the  uterus  produced  by  the 
rough  and  repeated  efibrts  of  young  practitioners  to  '  hook'  down 
the  OS  uteri."  Now,  this  certainly  is  only  condemning  the  abuse 
of  the  method ;  which  should  never  be  considered  as  a  valid  ob- 
jection against  the  employment  of  a  well-directed  one.  I  can  with 
very  great  confidence  declare,  I  have  never  known  even  pain 
excited  when  this  simple  operation  has  been  performed  by  my- 
self; nor  can  I  ever  believe  that  any  inconvenience  would  follow 
the  plan,  if  properly  performed  by  any  one  else.  If  we  are  to 
hesitate  to  recommend  useful  practical  operations,  because  they 
may  be  ill  performed  by  the  careless  or  the  ignorant,  we  should 
at  once  banish  from  medical  science  its  best  resources,  and  its 
greatest  triumphs. 

309.  Mr.  North  most  flatteringly  expresses  his  entire  belief, 
that /could  have  recourse  to  the  plan  recommended  without  in- 
jury to  my  patient;  now,  if  this  be  true,  it  must  necessarily  fol- 
low, that  it  is  not  essentially  dangerous;  and  if  the  directions 
laid  down  be  strictly  followed,  I  am  persuaded  it  cannot  be  even 
contingently  so.  I  agree  perfectly  with  this  gentleman,  and 
with  Dr.  Denman,  whom  he  has  cited  to  strengthen  his  objec- 
tions, that  time  may  sometimes  effect  delivery  in  the  obliquity 
in  question,  without  seriously  injuring  the  patient ;  but  it  cannot 

*  Treatise  on  Midwifery,  p.  15. 


124  OF  THE  OBLIQUITIES  OP  THE  UTERUS. 

do  this  without  causing  long  and  severe  suffering.  It  is  not  de- 
nied by  Mr-  N.  that  this  situation  of  the  uterus  may  create  some 
embarrassment  if  unreduced  ;  as  he  recommends  for  this  purpose, 
that  the  woman  should  be  placed  upon  her  back,  as  1  have  done; 
but  he  makes  no  provision  in  case  of  failure  from  the  change  of 
position,  except  that  time  will  overcome  it,  if  a  sufficient  quan- 
tity of  it  be  given. 

310.  In  the  case  under  consideration,  the  question  is  not,  whe- 
ther the  unaided  powers  of  the  uterus  may  not  eventually  over- 
come the  difficulty  caused  by  the  anterior  obliquity  of  this  organ. 
The  true  one  is,  whether  we  cannot  most  profitably  to  the  mother 
and  child,  interfere.  As  far  as  my  own  experience  goes,  I  can 
most  conscientiously  answer  this,  in  the  affirmative.  This  was 
the  opinion  of  Baudelocque,  from  whom  I  learn  this  treatment; 
and  he  is  certainly  authority  equal  to  Dr.  Denman. 

311.  Mr.  North  remarks  as  follows,  upon  a  part  of  the  plan  in 
question:  ^'According  to  the  directions  of  Dr.  Dewees,  we  are 
not  to  remove  the  finger  from  the  os  uteri,  <  until  the  proper  di- 
rection of  the  forces  and  the  axis  of  the  uterus  are  made  to  cor- 
respond.' It  must  obviously,  then,  be  impossible  for  the  practi- 
tioner to  determine  whether  the  favourable  change  in  the  position 
of  the  parts  is  the  result  of  his  assistance,  or  the  continued  uterine 
efforts  which  have  been  going  on."  I  would  inquire,  in  what 
the  difficulty  in  this  instance  lies.  Can  it  be  imagined,  that  a 
practitioner,  especially  one  who  appears  to  be  so  judicious  as  Mr. 
N.  should  for  a  moment  be  at  a  loss,  to  what  cause  he  should 
attribute  the  change  in  the  direction  of  axes;  the  descent  of  the 
head;  and  the  rapid  termination  of  a  labour,  after  establishing  a 
correspondence  between  the  mouth  of  the  uterus,  and  the  axis 
of  the  upper  strait?  Previously  to  the  interference,  hours  had 
been  fruitlessly  spent;  the  os  uteri  was  mounted  high  before  the 
projection  of  the  sacrum;  and  though  soft,  and  yielding,  no  exer- 
tion of  the  uterus  could  make  the  head  engage  in  it,  and  conse- 
quently could  not  descend  through  it;  but  in  a  few  moments,  all 
these  unpleasant  conditions  are  fiivourably  changed,  by  merely 
drawing  the  os  uteri  to  the  centre  of  the  pelvis,  (316,  317.)  Yet 
we  admit  that  the  head  may  be  forced  lower  into  the  pelvis  by 
the  long-continued  contractions  of  the  uterus,  but  it  must  be  re- 
collected when  this  is  the  case,  it  makes  its  way  by  stretching  the 
anterior  portion  of  this  organ,  (305,)  a  circumstance,  in  some  in- 


OP  THE  OBLIQTITIES  OF    THE  UTERUS.  125 

stances,  highly  dangerous,  and  not  by  passing  through  the  axis  of 
the  mouth.* 

312.  But  I  would  ask  in  all  sincerity,  what  is  to  be  apprehend- 
ed, if  the  rules  I  have  laid  down,  and  the  circumstances  under 
which  it  is  directed  we  should  act,  be  strictly  observed?  we  can- 
not see  either  difficulty  or  danger;  and  we  must  insist,  that  in 
the  cases  in  which  it  is  necessary  to  interfere,  it  is  a  duty  to  do  so; 
for  we  hold  it  to  be  a  sound  principle,  that  whenever  we  can 
spare  an  hour's,  or  even  less  of  unnecessary  pain,  it  is  right,  nay 
it  is  obligatory  upon  us  to  do  so.  We  are  not  to  permit  a  patient 
to  suffer  a  great  positive  evil,  from  the  apprehension  of  a  small 
contingent  one. 

313.  We  must  therefore  insist,  that  though  nature  unaided 
may  struggle  through  a  difficulty,  it  is  not  right  to  permit  her  to 
do  so,  if  we  can,  by  a  timely  and  judicious  interference,  abridge 
her  efforts.  Besides,  it  is  not  a  necessary  consequence,  that  na- 
ture can  perform  the  task  assigned  her,  with  entire  safety  to  the 
patient,  if  even  time  be  given;  for  her  efforts  are  far  from  being 
always  crowned  by  success,  or  always  free  from  hazard.  I  would 
therefore  still  insist,  because  it  so  entirely  comports  with  often- 
repeated  experiment,  that  it  is  the  duty  of  the  accoucheur,  in 
cases  of  anterior  obliquity,  always  to  act  as  has  been  directed, 
(306)  whenever  the  natural  forces  do  not  in  a  reasonable  time, 
establish  a  correspondence  between  the  axis  of  the  pelvis,  and  of 
the  OS  uteri,  and  when  the  latter  is  either  dilated,  or  easily  di- 
latable. And  we  must  farther  insist,  that  no  injury  can  possibly 
arise  from  this  simple  operation,  if  it  be  any  way  carefully  per- 
formed; but  by  employing  it,  much  time,  more  suffering,  and, 
this  without  risk,  may  be  saved  the  patient.  For  though  it  has 
chanced  to  be  the  good  luck  of  Mr.  N.  not  to  have  witnessed 
"a  case  in  which  the  unassisted  eflforts  of  nature  have  not  termi- 
nated the  labour  in  a  favourable  manner,"  yet  it  has  not  always 
fallen  to  the  lot  of  others,  to  have  seen  such  instances. 

314.  Indeed,  Mr.  N.  indirectly  confesses  he  has  never  seen 
the  case  for  which  we  recommend  interference;  he  consequent- 
ly cannot  be  a  competent  judge  of  the  necessity;  he  therefore 
should  not  condemn  those  for  acting,  who  have  been  under  the  ne- 
cessity to  do  so;  especially,  as  he  justifies  the  operation  under  the 
circumstances  for  which  we  direct  it,  in  the  following  words. 

*  Baudelocqe,  loc.  cit. 


126  OP  THE  OBLIQUITIES  OF  THE  UTERUS. 

"But  however  desirable  it  may  be  that  the  process  of  labour 
should  not  be  improperly  interfered  with,  it  is  equally  necessary 
that  we  should  not  withhold  our  aid  when  it  is  really  required. 
If  it  should  happen  that  the  uterine  efforts  do  not  gradually  bring 
the  OS  uteri  into  the  direction  of  the  axis  of  the  inferior  aperture, 
and  that  the  head  of  the  child  is  forced  down  by  each  pain, 
with  the  body  of  the  uterus  expanded  over  it,  it  would  then 
be  proper  for  the  practitioner  to  endeavour  to  place  the  parts 
in  a  more  favourable  situation,  by  the  practice  recommended 
by  Dr.  Dewees.'^  Now,  this  confession  is  all  that  is  required; 
for  we  only  direct  interference  in  the  precise  case  stated  by 
Mr.  N.  I  would  ask  then,  what  is  there  to  condemn,  in  what  I 
have  said  upon  this  subject?  for  I  have  advised  nothing,  in  which 
Mr.  N.  has  not  entirely  acquiesced,  by  the  concession  in  the  last 
quoted  sentence. 

315.  Within  my  own  knowledge,  this  case  has  been  mistaken 
for  an  occlusion  of  the  os  uteri;  and,  upon  consultation,  it  was 
determined,  that  the  uterus  should  be  cut  through  to  make  an 
artificial  opening  for  the  foetus;  they  thought  themselves  justified 
in  this  opinion,  first,  by  no  os  uteri  being  discoverable  by  the 
most  diligent  search;  and,  secondly,  by  the  head  being  about  to 
engage  under  the  arch  of  the  pubes,  covered  by  the  womb:  ac- 
cordingly, the  labia  were  separated,  and  the  uterine  tumour 
brought  into  view;  an  incision  was  made  by  a  scalpel  through 
the  whole  length  of  the  exposed  tumour,  down  to  the  head  of 
the  child — the  liquor  amnii  was  evacuated,  and  in  due  course  of 
time,  the  artificial  opening  was  stretched  sufficiently  to  give 
passage  to  the  child;  the  woman  recovered;  and  to  the  disgrace 
of  the  accoucheurs  who  had  attended  her,  was  delivered,  per  vias 
naturales,  of  several  children  afterwards — a  proof  that  the  ope- 
ration was  most  wantonly  performed. 

316.  I  have  found  more  than  once,  in  cases  of  extreme  ante- 
rior obliquity,  that  it  is  not  sufficient  for  the  restoration  of  the 
fundus,  that  the  woman  be  merely  placed  upon  the  back:  for  we 
are  also  obliged  to  lift  up,  and  by  a  properly  adjusted  towel  or 
napkin,  to  support  the  pendulous  belly,  until  the  head  shall  oc- 
cupy the  inferior  strait.  To  illustrate  this,  I  will  relate  one  of  a 
number  of  similar  cases,  in  which  this  plan  was  successfully  em- 
ployed.    Mrs.  0 ,  pregnant  with  her  seventh  child,  after  the 

seventh  month  was   much  afflicted  with  pain,  and   the  other 
inconveniences,  which  almost  always  accompany  this  hanging  of 


OF  THE  OBLIQUITIES  OP  THE  UTERUS.  127 

the  uterus;  and  was  obliged  to  wear  the  jacket  recommended 
above,  from  which  she  experienced  much  relief.  She  was  taken 
with  labour  pains  on  the  morning  of  the  10th  of  October,  1820; 
I  was  not  sent  for  until  about  noon — the  pains  were  frequent  and 
distressing,  and,  upon  examination  per  vaginam,  the  mouth  of  the 
uterus  was  found  near  the  projection  of  the  sacrum,  and  dilated 
to  about  the  size  of  a  quarter  of  a  dollar;  it  was  pliant  and  soft; 
and  during  a  pain,  the  membranes  were  found  tense  within  the 
OS  uteri;  but  did  not  protrude  beyond  it. 

317.  As  this  was  the  first  time  I  had  been  called  to  attend  this 
patient;  and  the  history  she  gave  of  her  former  labours,  repre- 
sented the  abdomen  to  be  equally  pendulous  in  each,  with  the 
exception  of  the  first;  I  waited  several  hours,  (the  patient  being 
on  her  left  side,)  for  the  accomplishment  of  the  labour.  During 
the  whole  of  this  period,  the  head  did  not  advance  a  single  line, 
nor  could  it;  as  the  direction  of  the  parturient  efforts,  carried  it 
against  the  projection  of  the  sacrum.  I  had  several  times  taken 
occasion  to  recommend  her  being  placed  upon  her  back;  but  to 
this  she  constantly  objected,  until  I  urged  its  absolute  necessity 
— she  at  length  reluctantly  consented.  When  upon  her  back,  it 
was  found  that  the  os  uteri  was  not  sufficiently  advanced  towards 
the  centre  of  the  superior  strait,  the  abdomen  was,  therefore, 
raised,  and  a  long  towel  placed  against  it;  and  it  was  kept  in  this 
situation,  by  its  extremities  being  firmly  held  by  two  assistants — 
at  the  same  time  I  introduced  a  finger  within  the  edge  of  the  os 
uteri,  as  directed  above,  (304,)  and  drew  it  towards  the  symphy- 
sis pubis,  and  then  waited  for  the  efi'ects  of  a  pain — one  soon  fol- 
lowed, and,  with  such  efficacy,  as  to  push  the  head  completely 
into  the  inferior  strait;  and  by  three  more,  it  was  delivered.  In 
this  case,  I  have  every  reason  to  believe,  that  many  hours  more 
would  have  passed  without  profit,  had  I  not  insisted  upon  the 
change  of  position;  and,  in  my  opinion,  it  most  decidedly  proves 
the  importance  of  correct  principles  in  the  art  of  midwifery.  Sec 
Baudelocque. 

318.  It  might  be  considered  as  highly  useful  in  such  cases,  that 
the  woman  lie  as  much  as  possible  upon  her  back,  even  from  the 
commencement  of  the  labour,  as  it  would  certainly  contribute  to 
the  restoration  of  the  displaced  uterus:  it  is  moreover  very  im- 
portant in  such  instances,  that  the  bowels  be  opened  either  by 
some  gentle  medicine,  or  by  an  injection,  that  no  accumulation 
of  fasces  may  take  place  in  the  rectum. 


128 


CHAPTER  X. 

OF  THE  TERM  OP  UTERO-GESTATION. 

319.  The  time  a  foetus  resides  in  uteri  is  not  precisely  deter- 
mined by  physiologists,  even  when  the  woman  is  placed  under 
the  most  favourable  circumstances  for  ascertaining  it.  It  seems, 
however,  from  the. best  calculations  that  can  be  made,  that  nine 
calendar  months,  or  forty  weeks  approaches  the  truth  so  nearly, 
that  we  scarcely  need  desire  more  accuracy,  could  it  be  obtained. 
There  are  unquestionably  many  causes  which  may  provoke  the 
uterus  to  contraction,  before  the  full  period  of  utero-gestation,  or 
before  it  might  take  place  spontaneously;  there  may  also  be 
some,  which  may  procrastinate  the  common  period.  The  fre- 
quency of  abortion,  and  the  occasional  occurrence  of  premature 
delivery,  sufficiently  prove  the  first;  and  the  very  much  more 
rare,  but,  nevertheless,  well  authenticated  instances  of  prolonged 
gestation,  puts  the  latter  almost  beyond  dispute.  But  of  the  latter 
I  shall  again  have  occasion  to  speak  more  at  large,  (325,  &c.)  Of 
the  premature,  however,  I  may  remark,  that  I  have  known  several 
instances,  where  labour  habitually  occurred  before  the  full  period; 
with  one  lady  it  always  happened  at  the  seventh  month;  and  in 
two  others,  it  regularly  took  place  at  the  eighth  month  of  preg- 
nancy. iVnd  of  the  protracted,  I  have  known  still  more  instances, 
where  every  circumstance  and  calculation,  rendered  it  nearly 
certain,  that  the  children  were  carried  ten  months,  or  even  a  little 
beyond  it. 

320.  We  have  no  certain  mark,  to  detect  the  instant  at  which 
conception  takes  place;*  and  consequently,  we  cannot  ascertain, 
with  absolute  precision,  the  exact  extent  of  time  the  fcctus  resides 
in  utero.  The  cessation  of  the  menses,  and  quickening,  are  the 
most  common  foundations  to  calculate  from;  but  these  must  ne- 

*  There  arc  many  popular  errors  upon  this  subject,  to  which  it  may  be  well 
to  say,  in  contradiction  of  them,  that  our  experience  fm-nishes  no  certain  mark, 
by  wliich  the  moment  conception  takes  place,  is  to  be  distinguished.  All  ap- 
peals by  the  woman,  to  particular  sensations  experienced  at  the  instant,  shoidd 
be  very  guardedly  received;  for  we  are  certain  they  cannot  be  rehed  upon; 
for  enjoyment  and  indifference  are  alike  fallacious.  Nor  are  certain  nervous 
tremblings,  nausea,  palpitation  of  the  heart,  the  sensation  of  something  flowing 
from  them  during  c(Htiou,  &.c.  more  to  be  relied  upon. 


OP  THE  TERM  OP  UTERO-GESTATION.  129 

cessarily  be  liable  to  considerable  variation;  since,  perhaps,  it  is 
not  erring  greatly,  to  say,  that  the  woman  is  liable  to  conceive, 
at  any  part  of  the  menstrual  interval:  and  that  she  may  quicken 
at  various  periods  of  gestation.  It  is  generally  supposed,  how- 
ever, that  the  most  favourable  instant  is,  immediately  after  the 
catamenial  evacuation  had  ceased;  perhaps,  this  is  so,  as  a  general 
rule;  but  it  is  certainly  liable  to  exceptions.  The  uncertainty  of 
the  moment  at  which  conception  takes  place,  will  always  em- 
barrass calculation;  since  a  latitude  of  from  two  to  three  weeks 
must  be  permitted. 

321.  But  opportunities  have  occurred  where  the  utmost  accu- 
racy must  have  prevailed:  one  presented  itself  to  my  notice, 
many  years  ago.  The  husband  of  a  lady  who  was  obliged  to  absent 
himself  many  months,  in  consequence  of  the  embarrassment  of  his 
affairs,  returned  one  night  clandestinely;  his  visit  being  only 
known  to  his  wife,  her  mother,  and  myself.  The  consequence 
of  this  visit  was  the  impregnation  of  his  wife.  The  lady  was  at 
this  time  within  a  week  of  her  menstrual  period;  and  as  this  did 
not  fail  to  take  place,  she  was  led  to  hope  she  had  not  suffered 
by  the  visit  of  her  husband.  But  her  catamenia  not  appearing  at 
the  next  period,  gave  rise  to  a  fear,  that  she  had  not  escaped;  and  the 
birth  of  a  child,  nine  months  and  thirteen  days  from  the  time  of 
of  this  clandestine  visit,  proved  her  apprehensions  too  well 
grounded. 

322.  This  case  is  remarkable  for  two  facts;  one,  that  a  woman 
in  perfect  health,  and  pregnant  with  a  healthy  child,  may  exceed 
the  period  of  nine  months,  by  several  days;  the  other  is,  that  a 
woman  may  become  impregnated  just  before  her  menstrual  dis- 
charge is  about  to  take  place,  and  not  have  it  interrupted — and 
also,  it  seems,  that  a  check  is  not  immediately  given  to  the  cata- 
menial flow,  by  an  ovum  becoming  impregnated.  This  fact 
has  perhaps  frequently  obtained;  or  at  least  more  frequently  than 
is  imagined,  and  has  thus  created  no  inconsiderable  error  in  cal- 
culation. Desormeaux  relates,  that  «  a  lady,  the  mother  of  three 
children,  became  insane.  Her  physician  considered  that  child- 
bearing  might  have  a  beneficial  influence  on  the  mental  disease, 
permitted  the  husband  to  visit  her,  under  condition  that  it  should 
be  once  only,  and  at  the  distance  of  three  months,  in  order  that 
if  conception  took  place,  there  might  not  be  a  risk  of  abortion, 

17 


130  OF  THE  TERM  OF  UTERO-GESTATION. 

from  farther  intercourse.  The  physician  and  attendants  made 
an  exact  note  of  the  time  when  the  husband  was  permitted  to 
visit  his  lady.  When  symptoms  of  pregnancy  appeared,  the  visits 
were  absolutely  and  totally  discontinued.  The  patient  was  ne- 
cessarily watched  by  the  female  attendants  required  for  her  ma- 
lady, and  was  moreover,  a  lady  of  the  strictest  principles  of  mo- 
rality. She  was  delivered  at  the  termination  of  nine  solar 
months  and  a  fortnight,  of  a  small  child,  of  which  she  was  deli- 
vered by  Desormeaux  himself."* 

323.  As  we  are  entirely  unacquainted  with  the  causes  which 
excite  contractions  in  the  uterus  for  the  purpose  of  expelling  its 
contents  at  the  expiration  of  nine  months  or  thereabouts,  so  we 
remain  ignorant  of  the  conditions,  both  on  the  part  of  the  uterus 
and  of  the  child,  to  make  these  causes  available— all  we  at  pre- 
sent know  upon  the  subject  is,  that  it  is  an  established  law;  but 
it  is  every  way  certain  that  this  law  arises  from  certain  condi- 
tions, of  which  we  are  altogether  uninformed,  t  As  the  period  of 
incubation  is  immutable,  in  every  particular  species  of  birds,  we 
have  some  reason  to  believe,  that  the  developement  of  the  fcetus 
has  some  agency  in  determining  the  period:  but  of  this,  we  can 
say  nothing  positive,  as  so  many  apparent  exceptions  present 
themselves. 

324.  Many  ingenious  hypotheses  have  been  proposed  to  ex- 
plain this  interesting  phenomenon;  but  all  of  which  fail  to  be 
satisfactory,  from  the  existence  of  one  fact — namely:  that  in  cases 
of  extra-uterine  conceptions,  the  uterus,  at  the  expiration  of  nine 
months,  is  as  certainly  thrown  into  painful  contractions,  of  shorter 
or  longer  continuance,  as  if  the  foetus  had  resided  within  its 
cavity.  And  to  these  we  may  add,  that  in  the  few  cases  of  very 
extended  gestation,  the  same  thing  has  as  constantly  occurred,  if 
these  cases  have  been  faithfully  related;  and  as  far  as  we  can 
judge  upon  this  subject,  there  does  not  appear  to  be  any  rational 
ground  to  suspect  their  fidelity.  Now  these  things  being  true, 
they  must  at  once  put  to  flight  the  ingenious  speculations  of  the 
theorist. 

325.  Be  the  exact  period  when  it  may,  sufficient  has  been  as- 


*  London  Medical  Gazette,  Dec.  12,  1829,  p.  344. 
f  See  par.  325,  and  following. 


OF  THE  TERM  OP  UTERO-GESTATION.  131 

certained  to  fix  the  common  one,  at  about  nine  months;  and  in 
making  calculations,  it  is  always  best  to  allow  a  little  latitude 
beyond  the  time  which  the  mere  stopping  of  the  menses  would 
indicate;  for  as  a  general  rule  it  will  be  found,  that  more  women 
are  impregnated,  a  few  days  after  this  evacuation,  than  at  any 
other  period. 

326.  We  are  aware  that  much  doubt  is  entertained,  and  much 
wit  has  been  expended,  upon  the  testimony  which  accoucheurs 
give  upon  the  absolute  duration  of  human  gestation ;  and  espe- 
cially since  the  discrepant  evidence  given  by  seventeen  profes- 
sional gentlemen,  in  the  Gardner  Peerage  cause.  But  it  should 
be  borne  in  mind,  that  doubt  is  not  proof;  nor  is  wit,  argument; 
consequently,  neither  should  be  permitted  to  have  an  undue  in- 
fluence. Yet  we  are  disposed  to  grant,  that  all  testimony  that 
contravenes  the  general  laws  of  nature  in  relation  to  this  subject, 
should  be  admitted  with  great  caution  ;  and  only  after  a  strict 
examination. 

327.  For  were  the  plea  of  the  possibility  of  an  unusual  exten- 
sion of  the  term  of  utero-gestation  made  a  common  one,  or  ad- 
mitted with  too  much  facility,  the  consequences  would  be  as 
extensive  as  mischievous.  But  this  cannot  very  well  happen 
under  its  present  limitations ;  as  public  opinion,  and  supposed 
correct  observation,  are  so  inveterately  fixed  upon  this  pointy 
that  little  danger  can  be  apprehended  from  an  occasional,  and  a 
well  qualified  admission  of  it. 

328.  Nature,  for  the  most  part,  is  pretty  steady  and  uniform 
in  her  operations;  and  perhaps  in  none  is  she  more  so,  than  in 
her  general  schemes  of  impregnation.  Yet  it  is  notorious,  even 
in  this,  her  favourite  process,  that  she  is  occasionally  so  vague, 
and  sometimes  so  whimsical,  that  perhaps  few  instances  exist  of 
absolute  uniformity.  These  remarks  will  apply  with  much  force, 
to  the  subject  in  question,  if  any  reliance  may  be  placed  upon 
apparent  facts,  or  upon  human  testimony ;  or  at  least,  as  far  as 
facts  and  testimony  are  concerned,  with  the  events  connected 
with  impregnation,  in  the  present  state  of  society. 

329.  How  much  more  uniform  nature  may  be  in  her  opera- 
tions in  savage  life,  we  have  no  facts  to  direct  us,  which  can  be 
unhesitatingly  received;  nor  would  it  perhaps  be  essential  to  the 
investigation  of  the  present  question,  as  it  could  not  have  a  bear- 


132  OP  THE  TERM  OF  UTERO-GESTATION. 

ing  upon  the  conduct  of  females  in  civilized  life;  thougli  it  would 
be  confessedly  curious,  if  not  highly  useful,  to  ascertain  the  de- 
gree of  her  uniformity,  or  the  extent  of  her  aberrations. 

330.  We  have  already  confessed,  that  we  are  altogether  igno- 
rant of  the  natural  cause  which  calls  the  uterine  fibre  into  action 
at  about  the  end  of  the  ninth  calendar  month ;  so,  we  cannot  deny 
but  that  the  operation  of  this  cause,  be  it  what  it  may,  can  be 
suspended  in  some  instances,  either  by  a  diminution  of  the  force 
of  the  cause,  or  by  some  change  in  the  disposition  of  the  uterus 
itself,  beyond  the  common  or  ordinary  limit  assigned  for  human 
gestation.  That  such  departures  from  the  general  rule  do  take 
place  from  time  to  time,  we  have  not  the  slightest  doubt;  and 
we  believe  this,  with  the  more  readiness,  because  it  does  not 
appear  to  be  confined  to  the  human  species.  For  if  we  are  to  be- 
lieve Tessier,  he  found  as  great  departures  from  the  ordinary 
rule,  among  several  of  the  inferior  animals  to  which  his  experi- 
ments were  directed,  as  is  declared  to  occur  with  the  human 
female. 

331.  As  the  experiments  of  the  naturalist  just  mentioned,  are 
highly  curious,  and  not  very  generally  known,  we  will  employ 
them  in  detail ;  and  at  the  same  time  consider  them,  as  furnish- 
ing an  argument  from  analogy,  in  favour  of  the  opinion  we  are 

attempting  to  support.* 

332.  "In  five  hundred  and  seventy-five  cows,  twenty-one  calv- 
ed between  the  two  hundred  and  fortieth  and  two  hundred  and 
seventieth  days,  average  two  hundred  and  fifty-nine ;  five  hundred 
and  forty-four  between  the  two  hundred  and  seventieth  and  two 
hundred  and  ninety-ninth  days,  average  two  hundred  and  eighty- 
two;  and  ten  between  the  two  hundred  and  ninety-ninth  and 
three  hundred  and  twenty-first  days,  average  three  hundred  and 
six;  average  of  the  whole,  two  hundred  and  eighty-two  days;  so 
that,  from  the  shortest  to  the  longest  period,  there  is  a  difierence 

*  Dr.  Beck  appears  unwilling  to  make  the  conclusions  of  Tessier  apply  to 
human  gestiition;  he  says, "these  facts  certainly  go  to  show  tliat  the  period 
of  gestation  is  Irregular  among  animals,  and  should  they  be  verified  by  suc- 
ceeding observers,  a  strong  argument  from  analogy  will  be  furnished  against 
its  uniformity  in  the  human  race.  It  must,  however,  be  recollected,  tliat,  even 
if  perfectly  estabhshed,  it  is  only  a  favourable,  and  not  a  decisive  proof." — 
Ekmenfs  of  MedicalJurisprudcnce,  Vol.  I.  p.  290. 


OF  THE  TERM  OP  TJTERO-GESTATION.  133 

of  eighty-one  days,  that  is,  more  than  one-fourth  of  the  average 
time." 

333.  "  In  two  hundred  and  seventy-seven  mares,  with  foal 
for  the  first  time,  twenty-three  foaled  between  the  two  hundred 
and  eighty-seventh  and  the  three  hundred  and  twenty-ninth 
days,  average  three  hundred  and  twenty-two  days;  two  hundred 
and  twenty-six  between  the  three  hundred  and  twenty-ninth 
and  three  hundred  and  sixtieth  days,  average  three  hundred  and 
forty-six;  and  twenty-eight  between  the  three  hundred  and  six- 
tieth and  four  hundred  and  nineteenth  days,  average  three  hun- 
dred.and  seventy-two;  average  of  the  whole,  three  hundred  and 
forty-seven  days;  difference  between  the  extremes,  one  hundred 
and  thirty-two  days." 

334.  "In  one  hundred  and  seventy  mares  which  had  foaled 
before,  twenty-eight  foaled  between  the  two  hundred  and  nine- 
tieth and  three  hundred  and  twenty-ninth  days,  average  three 
hundred  and  twenty-one;  one  hundred  and  twenty-eight  between 
the  three  hundred  and  twenty-ninth  and  three  hundred  and  sixtieth 
days,  average  three  hundred  and  forty-one;  and  fourteen  between 
the  three  hundred  and  sixtieth  and  three  hundred  and  seventy- 
seventh  days,  average  three  hundred  and  seventy;  average  of 
the  whole,  three  hundred  and  forty-one  days;  so  that  between 
the  shortest  and  the  longest  period,  there  was  a  difference  of 
ninety-seven  days,  more  than  one-fourth  of  the  mean  term." 

335.  "In  nine  hundred  and  twelve  sheep,  the  mean  time  of 
gestation  was  about  one  hundred  and  fifty-one  days,  and  the  ex- 
treme difference  only  eleven  days." 

336.  ''In  twenty-five  swine,  the  extremes  were  from  onehun- 
dred  and  nine  to  one  hundred  and  thirty-three  days." 

337.  "In  one  hundred  and  sixty-one  rabbits,  the  extreme 
terms  of  gestation  were  from  twenty-seven  to  thirty-five  days."* 

338.  Thus  we  see  in  the  brute  a  very  considerable  variety 
prevails  in  the  terms  of  utero-gestation;  and  to  which,  imme- 
diate credence  will  be  yielded.  And  though  no  moral  question 
can  arise  from  aberrations  in  them,  they  nevertheless  furnish  us 
with  very  interesting  facts,  from  which  most  important  deductions 
must  be  made  in  favour  of  the  occasional  extension  of  the  terms 
of  gestation  in  the  human  female. 

*  See  Beck's  Elements  of  Medical  Jurisprudence. 


134  OP  THE  TERM  OF  UTERO-GESTATION. 

339.  In  my  mind,  the  period  of  utero-gestation  has  no  absolute 
period;*  and  I  am  of  opinion  that  variations  in  the  term  of  this 
process  do,  and  will  constantly  occur;  since,  so  far  as  calculation 
and  observation  have  gone,  they  are  in  direct  opposition  to  the 
opinion,  that  the  period  of  human  gestation  is  governed  by  an 
immutable  law. 

340.  I  have  most  entirely  satisfied  myself,  that  this  process 
extended  in  one  instance,  (321,)  thirteen  days  beyond  nine  en- 
tire calendar  months;  and  I  have  had  every  evidence  this  side 
of  absolute  proof,  that  it  has  been  prolonged  to  ten  calendar 
months,  as  an  habitual  arrangement,  in  at  least  four  females. that 
I  have  attended ;  that  is,  each  of  these  women  went  one  month 
longer  than  the  calculations  made,  from  an  allowance  of  ten  or 
twelve  days  after  the  cessation  of  the  last  menstrual  period,  and 
from  the  quickening,  which  was  fixed,  at  four  months, 

341.  Besides,  a  case  within  a  short  period  has  occurred  in  this 
city,  where  the  lady  was  not  delivered  for  full  ten  months  after 
the  departure  of  her  husband  for  Europe;  yet  so  well,  and  so 
justly  too,  did  this  lady  stand  in  public  estimation,  that  there  did 
not  attach  the  slightest  suspicion  of  a  sinister  cause. 

342.  We  are  fully  aware,  that  all  we  have  said,  or  could  say, 
on  this  subject,  would  not  amount  to  legal  proof,  that  the 
period  of  utero-gestation  may  exceed  by  a  considerable  number 
of  days,  or  even  months,  the  ordinary  term,  or  the  period  of 
nine  calendar  months.  Yet,  we  are  certain,  that  a  very  different 
opinion  would  be  formed  out  of  a  court,  by  the  very  gentlemen, 
who  so  ingeniously  contrive  within  it,  to  create  doubts  upon  this 
point:  for  we  sincerely  believe,  that  the  question  when  consider- 
ed in  the  abstract  only,  would  be  determined  in  favour  of  the 
possibility  of  this  extension. 

343.  To  put  this  question  entirely  at  rest,  would  require  such 
a  combination  of  precautions,  and  such  peculiarity  of  experiment, 
as  to  make  us  believe  they  will  never  be  executed  by  design ;  and 
we  must  feel  how  far  from  being  satisfactory  they  would  be,  were 
they  performed  by  chance.  Therefore,  at  present,  we  can  only 
rely  upon  such  evidence  as  shall  be  afforded   by  females  them- 

•  By  this  I  would  be  understood  to  mean,  that  tliis  process  is  not  undeviatingly 
fixed  to  the  lapse  of  an  absolute  n'umber  of  days;  and  that  the  nearest  we  can 
approach  is  witliin  a  few  days  of  nine  months,  one  way  or  tlie  other. 


OF  THE  TERM  OF  UTERO-GESTATION.  135 

selves,  when  examined  upon  the  points  which  have  a  direct  bear- 
ing upon  the  subject. 

344.  For  the  most  part,  in  inquiring  into  this  subject,  we  can 
have  information  but  upon  three  poi^nts;  namely,  the  time  of 
cessation  of  the  last  menstrual  period ;  the  time  of  quickening; 
and  the  time  of  delivery;  and  upon  the  first  two,  it  is  confessed, 
the  woman  is  apt  to  be  rather  vague.  With  a  view,  however,  of 
arriving  at  some  general  and  satisfactory  conclusion,  it  might  be 
well,  that  every  obstetrical  practitioner  inquire  of  his  patient 
whenever  his  attendance  is  bespoke,  for  information  on  the  two 
first  points;  to  make  a  note  of  the  answers  he  may  receive; 
and  after  delivery  has  taken  place,  to  faithfully  record  that  event. 
In  time,  he  will  have  accumulated  sufficient  data,  to  warrant  a 
general  average  of  the  number  of  days  occupied  by  gestation.  But 
above  all,  he  should  Hote,  especially  in  the  married  woman  who 
may  have  no  sinister  object  in  the  statements  she  makes,  any  re- 
markable circumstance,  that  may  tend  to  fix  the  period  of  con- 
ception with  more  than  usual  precision.  In  an  ample  practice, 
such  opportunities  every  now  and  then  occur;  and  when  they 
do,  they  should  be  looked  upon  as  too  valuable  to  be  neglected, 
or  to  be  only  treasured  in  the  memory.  It  will  readily  occur  to 
the  reader,  how  such  occasions  may  present  themselves. 

345.  I  would  not  wish  to  be  understood,  in  what  has  been  said, 
as  I'ecommending  too  much  facility  of  credence  in  the  ipsa  dixit 
of  the  woman;  on  the  contrary,  from  the  importance  of  the  sub- 
ject in  every  point  of  view,  I  would  advise  the  utmost  caution  of 
investigation  especially  with  those  who  may  have  made  up  their 
minds  upon  either  side  of  the  question;  for,  agreeably  to  the  old 
adage,  "  what  we  wish  to  be  true,  we  can  easily  believe." 

346.  Dr.  Beck,  the  ingenious  and  successful  author  of  '*  Ele- 
ments of  Medical  Jurisprudence,"  treats  this  subject  with  a  le- 
vity that  almost  amount  to  ridicule.  We  were  severely  disap- 
pointed at  this ;  for  we  had  hoped  more  from  him ;  especially, 
as  he  has  treated  so  many  of  his  subjects  with  so  masterly  a  hand. 
In  our  opinion,  he  dismisses  this  subject  with  much  more  brevity 
and  despatch  than  its  claims  demand ;  and  this  without  the  use 
of  a  single  argument,  that  can  be  called  conclusive. 

347.  He  says,  ''It  is  astonishing,  and  I  will  add,  ridiculous, to 
view  the  ardour  with  which  writers  have  advocated  this  doc- 


136  OP  THE  TERM  OP  UTERO-GESTATION. 

trine"  (of  delayed  gestation,)  Vol.  I.  p.  292.  We  would  ask 
why  it  is  cither  astonishing  or  ridiculous,  that  writers  should 
engage  warmly  in  an  inquiry,  which  involves  so  many  important 
points  as  regards  morals  and  property? 

348.  We  admit,  that  the  adoption  of  every  history  upon  re- 
cord purporting  to  be  a  case  of  extended  gestation,  would  be  ab- 
surd; or,  to  approve  of  every  decision  of  a  court  in  favour  of  the 
woman,  would  certainly  be  sinning  against  our  better  judgment. 
Yet,  we  hold  it  would  be  every  way  unsatisfactory  to  the  philo- 
sopher and  the  philanthrophist  who  might  be  desirous  of  investi- 
gating this  subject,  to  be  told,  by  one  of  the  best  medical  jurists 
of  the  age,  that  a  calm  and  delibera,te  examination  of  these  histo- 
ries, (of  extended  gestation,)  "must  certainly  lead  to  a  total  dis- 
belief of  the  doctrine  of  protracted  gestation,"  p.  298.  And  all 
this  is  said,  without  adducing  opposing  facts,  or  the  employment 
of  any  apposite  reasoning. 

349.  Because  an  occurrence  is  rare,  it  should  not  be  declared 
impossible,  especially  upon  slight,  or  inadequate  ground;  for  no- 
thing is  more  common  than  the  abuse  of  general  rules.  W^e  do 
not  hesitate  to  admit,  there  is  a  common,  or  a  general  period 
for  the  termination  of  gestation,  in  every  class  of  the  mammalia; 
and  with  the  human  female,  that  period  is  from  forty  to  forty-one 
weeks;  and  this  epoch  forms  the  general  rule.  This  being  grant- 
ed, the  question  must  be  upon  the  exception,  if  the  exception 
exist ;  or,  in  other  words,  we  must  inquire,  can  the  term  of  ges- 
tation exceed  the  general  period? 

350.  We  must  ask,  first,  do  exceptions  to  the  rule  just  stated, 
really  exist?  And  second,  if  they  do,  we  must  try  to  ascertain 
to  what  extent  this  deviation  in  utero-gestation  ma}'  have  been 
extended. 

351.  First.  All  writers  upon  this  subject,  and  even  those  who 
are  unfavourable  to  the  doctrine  of  protracted  gestation,  admit, 
there  may  occasionally  be  a  diflerence  of  from  one  to  two  weeks 
in  the  ordinary  period  assigned  for  this  process.  This  being 
granted,  the  question,  by  what  law  is  this  variation  of  period  re- 
gulated, will  naturally  present  itself.  For,  if  the  uterus  fail  to 
conform  to  the  law  by  which  it  is  said  to  be  governed  in  the  pro- 
duction of  labour  at  the  exact  time  fixed  upon  by  some,  there 
must  be  a  cause  for  the  aberration;  and,  if  there  be  a  cause  for 


OF  THE  TERM  OF  UTERO-GESTATION.  137 

the  aberration,  we  would  ask,  how  is  its  limit  to  be  determined? 
for  the  cause  which  is  capable  of  suspending  the  regular  display 
of  uterine  contraction  for  a  week  or  a  fortnight,  beyond  its  pre- 
scribed time,  may,  upon  certain  occasions,  be  equal  to  prevent  it 
for  some  time  longer.  How  can  we  then  pretend  to  fix  a  limit 
to  the  suspension,  so  long  as  we  remain  altogether  ignorant  of  the 
governing  cause,  or  of  the  condition  of  the  uterus,  which  shall 
render  the  application  of  this  cause  available? 

352.  It  is  in  vain  to  say,  the  thing  cannot  be,  because  we  do 
not  undei'stand  how  it  can  be ;  or,  because  it  appears  to  violate 
a  law  of  the  animal  economy.  This  question  cannot  be  settled 
by  argument;  facts,  alone,  must  decide  it,  if  it  ever  be  put  en- 
tirely to  rest.  We  are,  therefore,  not  disposed,  from  what  we 
think  we  have  ascertained  upon  this  subject,  to  be  seduced  from 
the  opinions  we  have  formed,  by  the  specious,  or  perhaps,  more 
properly,  the  flippant  conclusions  of  Louis;  and,  upon  which, 
Dr.  Beck  seems  willing  to  rest  his  cause,  p.  297. 

353.  Dr.  Beck  says,  that  Louis,  among  other  arguments,  de- 
clares, first,  "  That  the  laws  of  nature  on  this  subject  are  immu- 
table." What  are  we  to  understand  by  this  assertion?  Is  it,  that 
the  laws  of  nature  are  fixed,  and  without  variation  in  the  busi- 
ness of  procreation  ?  If  they  are,  as  regards  the  term  of  utero- 
gestation,  it  is  the  only  point  in  which  this  exactitude  exists  in 
the  whole  work  of  generation;  and  for  which  it  would  be  very 
diJEcult  to  assign  an  adequate  reason;  for,  "nature  works  not  by 
partial  but  by  general  laws."  It  is,  as  far  as  we  can  determine, 
as  special  a  law,  that  the  foetus  be  developed  in  the  uterus,  as 
that  it  shall  not  tarry  there  beyond  nine  months;  yet  we  find  ex- 
ceptions to  this,  by  its  being  discovered  in  the  ovarium,  tube,  or 
abdomen.  It  is  a  special  law,  that  the  foetus  shall  have  a  head, 
a  heart,  arms,  or  legs,  yet  we  every  now  and  then  find  one,  defi- 
cient in  one  or  more  of  these  parts,  &c.  &c. 

354.  Second.  "  That  the  foetus  at  a  fixed  period,  has  received 
all  the  nourishment  of  which  it  is  susceptible  from  the  mother, 
and  becomes,  as  it  were,  a  foreign  body."  How  is  this  proved? 
No  proof  is  offered;  there  is  nothing  but  a  broad  assertion,  which 
is  contradicted  by  almost  daily  experience,  (if  we  are  to  under- 
stand it  as  we  believe  Mons.  Louis  intended  it  should  be,  namely, 
that  there  is  a  definite  and  an  invariable  period,  beyond  which 
the  foetus  cannot  be  nourished;  or  that  the  mother  could  not 

18 


138  OF  THE  TERM  OP  UTERO-GESTATION. 

grant  supplies,)  if  any  reliance  can  be  put  upon  human  testimony; 
or  upon  facts,  which  we  have  indisputably  witnessed  in  a  number 
of  instances.  Now,  if  there  be  one  single  exception,  this  "im- 
mutable law  of  nature,"  as  laid  down  by  him,  must  fall  to  the 
ground. 

355.  Besides,  the  foetus  cannot  be  considered,  "as  it  were,  a 
foreign  body,"  so  long  as  it  preserves  its  vitality,  and  its  connec- 
tion with  the  uterus. 

356.  Third.  "That married  women  are  very  liable  to  error  in 
their  calculations."  Admitted;  but  it  does  not  by  any  means 
follow,  that  there  has  been  an  error  in  calculation,  in  every 
instance  purporting  to  be  a  case  of  protracted  utero-gestation; 
consequently,  until  it  be  proved,  that  agreeably  to  a  law  of  nature, 
the  uterus  will  not  permit  a  foetus  to  remain  within  its  cavity, 
beyond  a  fixed  and  never-varying  period,  we  have  a  right  to  be- 
lieve, from  both  reasoning  and  observation,  that  the  period  com- 
monly assigned,  has  been  very  considerably  exceeded.  See 
Cases  1.,  II. 

357.  Fourth,  "  That  the  decisions  of  tribunals,  in  favour  of 
protracted  gestation,  cannot  overturn  a  physical  law."  This  is 
also  admitted;  but  let  it  be  first  proved,  that  protracted  gestation 
and  the  decisions  are  at  variance  with  a  physical  law,  before  it 
be  considered  as  violated. 

358.  Fifth.  "That  the  virtue  of  females  in  these  cases, 
is  a  very  uncertain  guide  for  legal  decisions."  Here  we  are 
decidedly  at  issue;  for  the  virtue  of  the  female,  in  its  absolute 
sense,  and  practice,  is  one  of  the  most  decisive  evidences  in 
favour  of  protracted  gestation.  And  this,  must  be  admitted, 
by  even  our  opponents;  but  to  prevent  the  conclusion  which 
would  irresistibly  follow  from  this  concession,  they  deride  its 
existence  either  directly  or  covertly,  in  every  instance 
purporting  to  be  a  case  of  protracted  gestation.  For,  on  the 
one  hand,  Louis  declares  the  virtue  of  femalas  to  be  un- 
certain guides  in  legal  decisions;  and  that  married  females 
are  very  liable  to  error  in  their  calculations ;  while  Dr.  Beck 
more  openly  decides,  that  "a  calm  and  deliberate  examina- 
tion of  these  histories,"  (of  protracted  gestation,)  "will  lead 
to  a  total  disbelief  of  the   doctrine   of   protracted   gestation.* 

•  Dr.  Beck  relates  the  following  histories?  we  have  abridged  them,  but  with- 
out losing  the  material  points. 


OP  THE  TERM  OP  UTERO-GESTATION.  139 

There   are    many,"    he    continues,  "that   evidently    bear    the 
impress  of  vice,  while  the  most  favourable  are  so  liable  to  have 

"Bartholin  says  a  young  woman  declared  herself  to  have  been  seduced;  she 
was  strictly  guarded  after  this,  and  was  delivered,  sixteen  months  aftei)>  of  a 
living  child."     Fodere,  Vol.  2.  p.  183. 

•'In  1638,  a  woman  was  delivered  of  a  child,  one  year  and  thirteen  days  after 
the  death  of  her  husband.  She  suffered  with  severe  labour  pains  one  month 
previously.  The  child's  head  was  without  fontanelles.  The  faculty  of  Leipsic 
declared  it  to  be  legitimate."     Valentin's  Pandects,  Vol.  1.  p.  142. 

"A  man  died  on  the  2d  of  December,  1687,  after  being  eight  days  in  ex- 
tremis,- 16th  of  October  following,  his  wife  was  delivered  of  a  son.  The  faculty 
of  Geissen  declared  it  to  be  legitimate."     Ibid. 

"Le  Seur  was  struck  with  apoplexy.  May  14th,  1671,  and  died  on  the  16th. 
His  wife  had  not  been  pregnant  during  the  six  years  of  their  marriage.  On  the 
11th  of  the  succeechng  September  she  declared  herself  pregnant,  and  on  the  17th 
of  April,  1672,  (eleven  months  and  four  days  after  his  illness,)  she  was  deliver- 
ed of  a  son.  The  relatives  of  the  husband  contested  its  legitimacy,  and  obtained 
a  decree  in  their  favour,  but  on  appealing  to  the  parliament  of  Rouen,  the  cause 
was  decided  in  favour  of  the  widow,  on  the  score  of  the  goodness  of  character, 
and  on  the  possibihty  of  protracted  gestation.  The  following  case  is  related  by 
Heister : — A  woman  was  delivered  thirteen  months  after  the  death  of  her  hus- 
band; the  individuals  interested,  were  about  to  contest  the  legitimacy  of  the 
child,  but  were  deterred  from  it  by  the  excellence  of  her  character.  So  con- 
vinced was  one  Christopher  Misnerus,  who  had  acted  as  shopkeeper  during  her 
widowhood,  that  he  married  her  shortly  after,  and  had  two  children  by  her,  and 
each  of  them  was  born  after  a  gestation  of  thirteen  months." 

"  Duhgnac  testified,  that  his  wife  with  two  children  went  thirteen  months  and 
an  half,  and  with  a  third  eleven  months.  La  Cloture  also  gave  an  opinion  in 
favour  of  the  widow,  and  quoted  several  similar  cases  from  his  own  observa- 
tion." 

"  Charles ,  aged  upwards  of  seventy -two  years,  married  Renee,  aged 

thu-ty  years.  They  were  married  nearly  four  years  without  having  issue.  On 
the  7th  of  October,  1762,  he  was  seized  with  fevei^  and  violent  oppression,  which 
remained  until  his  death.  The  last  symptoms  were  so  severe,  that  he  was  forced 
to  sit  in  his  bed,  nor  could  he  move  without  assistance.  In  addition  to  these, 
he  was  seized  with  dry  gangrene  of  the  leg  on  the  21st,  and  with  this  accumu- 
lation of  disease  he  gradually  sunk,  and  died  on  the  17th  of  November,  aged 
seventy-six  years.  Renee  had  not  slept  in  the  chamber  during  his  illness;  but 
about  three  and  a  half  months  after  his  death  she  suggested  that  she  was 
pregnant,  and  on  the  3d  of  October,  1763,  (within  four  days  of  a  year  since 
the  illness  of  her  husband,  and  ten  months  and  seventeen  days  after  his 
death,)  she  was  delivered  of  a  healthy,  well-formed,  and  full-sized  child. 
The  opinion  of  I.ouis  was  asked  in  this  case,  and  he  declared  the  offispring  was 
illegitimate." 

The  above  cases,  notwithstanding  Dr.  Beck's  scepticism,  appear,  (with  the 
exception  of  the  last,)  to  be  well-attested  instances  of  prolonged  gestatioK.  The 


140  OF  THE  TERM  OF  UTERO-GESTATION. 

arisen  in  error,  that  scepticism  must  appear  unavoidable,"  p.  298. 
^'This  reasoning,"  says  Dr.  Beck,  "appears  to  me  to  carry  great 
weight,  and  Mahon,  in  his  chapter  on  this  subject,  adds  several 
sensible  remarks  in  confirmation  of  it.  He  observes,  that  'if  the 
doctrine  be  true,  that  the  children  of  old  people  are  longer  in 
coming  to  maturity,  it  would  have  been  confirmed  by  experience, 
which  it  is  not.'"  Now,  we  cannot  perceive  anything  very 
profound  in  this  observation;  on  the  contrary,  we  think  it  is 
marked  by  much  oversight — for  it  is  contended,  by  the  opposers 
of  the  doctrine  of  protracted  gestation,  that  there  is  no  absolute 
certainty  of  the  moment  at  which  conception  takes  place,  as  the 
stopping  of  the  menses  is  not  a  guide;  or,  at  what  period  the 
woman  may  quicken,  as  that  differs  in  difterent  women,  and  at 
difierent  times  in  the  same  woman;  consequently,  there  may  be 
much  error  in  their  calculations;  yet,  with  no  better  data,  Mahon 
insists,  "that  if  the  doctrine  be  true,  that  the  children  of  old 
people  are  longer  in  coming  to  maturity,  it  would  have  been  con- 
firmed by  experience." 

359.  We  would  ask,  how  could  this  have  been  confirmed  by 
experience,  if  they  would  not  rely  upon  the  only  data  they  could 
possess?  For  the  same  objections  must  attach  to  the  means,  and 
mode  of  calculation,  in  both  instances;  and  if  they  be  rejected  in 
one  case,  they  must  in  the  other. 

first  case,  from  Bartholin,  is  particularly  in  point,  and  well  wortliy  of  considera- 
tion. To  us,  it  appears  a  little  sturdy  on  the  part  of  Dr.  Beck,  not  to  have  given 
a  little  more  credit  to  the  cases  and  authorities,  he  has  so  liberally  quoted.  Had 
he  have  done  so,  it  might  have  saved  the  expression  of  contempt,  for  those  who 
differ  in  opinion  with  him  in  tjjis  point,  contained  in  the  following  advice  to 
them.  "  I  recommend  to  those  who  intend  embracing  tlie  doctrines  of  protract- 
ed gestation,  an  examination  of  the  following  case.  If  they  can  satisfy  tlieir 
minds  respecting  it,  all  difficulties  on  this  subject  will  vanish.  The  husband 
had  been  absent  four  years,  at  the  end  of  which  period,  the  wafe  brought  forth 
a  child.  She  pleaded  that  her  conception  had  taken  place  through  the  force  of 
imagination  alone — 'utmulierper  fortem  imaginationem  putaverit,  se  in  in- 
somniis  rem  habuisse  cum  marito,  atque  sic  concepisse.'  The  parliament  of 
Grenoble,  to  whom  this  case  was  referred,  declared  the  offspring  legitimate. " — 
Metzger,  p.  416.  Schkgel,  Vol.  2,  p.  148. 

Had  Dr.  Beck  confined  his  ridicule  to  tlie  above,  and  a  few  other  cases,  almost 
as  preposterous  and  incredible,  we  should  have  been  better  pleased  with  his  mode 
of  treating  this  subject;  for  it  is  not  into  the  truth  of  such  stories  that  we  mean 
to  inquire ;  nor  from  such  vague  testimony,  that  we  mean  to  draw  our  inferences. 


OF  THE  TERM  OP  UTERO-GESTATION.  141 

360.  '<  Grief  also,  and  the  depressing  passions,  are  much  relied 
upon,  as  possessing  a  delaying  power;  but  certainly  these  are 
more  apt  to  produce  abortion,  than  protracted  gestation."  We  do 
not  know  the  fact,  but  we  are  persuaded  from  these  last  observa- 
tions, that  Mahon  was  not  an  accoucheur  of  experience;  for  had  he 
been  extensively  engaged  in  the  practise  of  midwifery,  he  could 
not  have  failed  to  observe  that  ''grief  and  the  depressing  pas- 
sions," have  "  a  delaying  power;"  and  that  they  do  not  dispose 
to  abortion.  Passions  and  emotions  of  the  mind,  have  this  ten- 
dency when  in  excess;  but  "  grief  and  the  depressing  passions," 
have  not.  On  the  contrary,  it  is  in  strict  conformity  with  our 
experience  in  a  considerable  number  of  cases,  that  they  have  a 
delaying  influence. 

361.  "That  the  menses  in  married  women  may  be  suppressed 
not  only  from  disease,  but  from  affections  of  the  mind,  or  acci- 
dental causes,  which  do  not  immediately  impair  the  health,  while 
the  increase  of  volume  in  the  abdomen  may  originate  from  this, 
or  from  numerous  other  causes." 

362.  We  have  admitted,  that  the  disappearance  of  the  menses, 
is  by  no  means  to  be  exclusively  relied  upon;  but  when  the 
stoppage  shall  correspond  with  the  period  of  quickening,  a 
pretty  near  estimate  may  be  formed.  And  it  may  be  proper  to 
observe,  that  when  the  menstrual  discharge  fail  in  the  married 
woman,  hitherto  healthy  and  regular,  the  presumption,  that  it 
is  arrested  by  pregnancy,  is  strengthened ;  especially,  as  when 
this  happens  from  either  disease,  or  "affections  of  the  mind,"  it 
is  rare  for  impregnation  to  take  place  during  the  continuance  of 
the  suppression. 

363.  "If  this  doctrine  be  allowed,  how  shall  we  distinguish  a 
delayed  child  from  one  that  is  born  at  nine  months;  and  by  what 
means  are  we  to  detect  fraud  in  such  cases?" 

364.  With  the  difficulties  which  may  be  presented  to  the  me- 
dical jurist  by  these  cases,  we  have  nothing  to  do.  In  our  opi- 
nions, the  fact  of  prolonged  gestation  is  established  beyOnd  con- 
troversy ;  and  this  being  so,  it  rests  with  those  who  have  the  set- 
tlement of  the  question,  to  find  out  the  respective  marks,  which 
may  distinguish  each  case. 

365.  "  Certainly,  as  far  as  we  can  judge  from  the  narratives 
given,  the  infants  born  after  protracted  gestation,  were  not  dis- 
tinguished for  size,  or  other  appearances  of  maturity." 


142  OP  THE  TERM  OP  TJTERO-GESTATION. 

366.  This  declaration  is  at  least  at  variance  with  the  opinions 
of  Mauriceau,  Lamotte,  and  Orfila ;  as  well  as  with  that  of 
Dr.  Hopkins,  who  gave  evidence  in  the  Gardner  Peerage 
cause.  See  "  Minutes  of  the  Medical  Evidence,"  &c.  by  Dr. 
Lyall,  p.  71. 

367.  And  were  "  the  infants  born  after  protracted  gestation  not 
distinguished  by  size  or  other  appearances,"  it  would  not  militate 
in  the  slightest  degree  against  the  doctrine;  as  we  are  of  opinion, 
that  the  tardy  developement  of  the  foetus,  may  be  one  of  the  causes 
of  delayed  gestation. 

368.  We  were  at  one  period  opposed  to  the  doctrine  of  pro- 
tracted gestation;  for  we  had  adopted  that  of  the  immutable  na- 
ture of  this  operation,  as  regarded  duration.  But  the  case  already- 
referred  to,  (321,)  convinced  us  that  the  period  of  nine  calendar 
months  could  certainly  be  exceeded  by  at  least  thirteen  days. 
This  led  us  to  a  careful  investigation  of  the  subject,  and 
which  has  resulted  in  the  entire  belief,  that  the  commonly 
fixed  period  may  be  extended  from  thirteen  days  to  six  weeks, 
under  the  influence  of  certain  causes  or  peculiarities  of  consti- 
tution. 

369.  Nor  do  we  feel  disposed  to  abandon  this  opinion,  by  all 
the  ridicule  which  has  been  heaped  upon  it ;  nor  from  the  appre- 
hension that  our  cherishing  it  will  have  the  slightest  tendency  to 
subvert  good  morals,  or  to  offer  inducements  to  the  wicked  and 
designing,  to  practise  upon  either  the  credulity  of  husbands,  or 
the  good  faith  of  friends.  The  checks  to  impositions  of  this  kind, 
are  both  certain,  and  numerous ;  and  they  would  not  fail  to  be 
employed  against  the  attempt. 

370.  We  have  upon  record  several  remarkable  histories  of 
modern  date;  in  addition  to  those  already  noticed,  which  seem  to 
establish  beyond  doubt,  that  human  utero-gestation  may  very 
much  exceed  nine  calendar  months.  And  as  they  are  not  within 
general  reach,  it  may  be  acceptable  to  the  reader  to  have  them 
presented. 

371.  Case  I.  A  woman,  aged  twenty-seven  years,  though 
much  emaciated  and  very  weak,  in  the  month  of  October,  1820, 
had  all  the  symptoms  of  pregnancy.  About  the  middle  of  the 
fifth  month  she  began  to  feel  the  motions  of  the  child,  and  at 
the  end  of  the  ninth  felt  the  precursory  pains  of  labour.     The 


OF  THE  TERM  OP  UTERO-GESTATION.  143 

surgeon,  who  was  called,  found  the  pains  weak,  and  the  os  uteri 
not  much  dilated,  though  sufficiently  so  to  allow  him  to  feel  that 
the  vertex  presented.  In  consequence  of  the  extreme  weakness 
of  the  patient,  she  was  treated  with  permanent  and  diffusihle  sti- 
muli, and  with  so  much  advantage,  that  at  the  end  of  six  weeks 
she  had  regained  the  appearances  of  health,  and  had  returned  to 
her  ordinary  occupations. 

372.  A  few  days  after  the  coming  on  of  the  pains,  the  motions 
of  the  child  became  weaker,  and  eventually  ceased.  The  size  of 
the  belly  diminished,  and  the  child  appeared  turned  to  the  left 
side.  The  menses  appeared  in  the  tenth  month,  and  returned  re- 
gularly afterwards.  In  December,  1821,  Mr.  Penker  was  called 
into  consultation,  and  advised  forcible  delivery,  which  was  not 
consented  to.  In  Octobex,  1822,  he  found  the  os  uteri  above 
the  symphysis  pubis,  inclined  obliquely  half  an  inch  to  the  right 
side,  with  the  fundus  to  the  left. 

373.  The  posterior  surface  of  the  uterus  had  descended  so  low 
in  the  pelvis,  as  not  to  be  more  than  an  inch  and  a  half  from  the 
orifice  of  the  vagina;  and  was  not  thicker  than  a  double  sheet  of 
paper.  The  back  and  feet  of  the  child  could  be  felt  through 
the  abdomen.  Such  was  the  state  of  the  patient  in  March,  1823, 
up  to  v/hich  time,  she  had  refused  to  submit  to  any  operation. 
The  relator  of  this  case  promises  the  sequel  at  some  future 
time. 

374.  The  translator  of  the  above  history  has  favoured  us  with 
the  following  remarks  upon  it.  "Although  this  case  is  described 
as  a  uterine  pregnancy,  there  are  some  circumstances  connected 
with  it,  sufficient  to  suggest  a  doubt  on  that  point.  If  not  extra- 
uterine, there  is  every  probability,  that  it  is  an  instance  of  retro- 
version, continuing  through  the  whole  period  of  pregnancy,  an 
occurrence  often  mistaken  for  the  real  extra-uterine  case,  as  has 
been  fully  proved  by  Dr.  Merriman  in  his  ingenious  essay  on 
that  subject." 

375.  It  would  have  afforded  us  much  pleasure,  and  perhaps 
equalinstruction  had  the 'translator"  favoured  us  with  the  points 
of  resemblance  between  this  case  and  an  extra-uterine  concep- 
tion; or,  between  it  and  a  "case  of  retroversion  continuing 
through  the  whole  period  of  pregnancy."  For  as  regards  our- 
selves, we  do  not  see  the  slightest  resemblance  to  either  of  his 
supposed  cases. 


144  OF  THE  TERM  OF  UTERO-GESTATION. 

376.  It  could  not  have  been  an  extra-uterine  case,  because  we 
are  distinctly  told,  that  "the  os  uteri  was  not  much  dilated, 
though  sufficiently  so  as  to  permit  him,  (the  attendant,)  to  ascer- 
tain that  the  vertex  presented."  That  settles  this  part  of  the 
question. 

377.  As  regards  its  resemblance  to  a  case  of  retroversion  at 
full  time,  it  is  equally  out  of  the  question.  1st.  Because  up  to  the 
ninth  month,  there  is  no  symptom  recorded,  that  would  lead  to 
the  suspicion  that  this  accident  had  taken  place.  2d.  Because,  up 
to  this  period,  the  os  uteri  is  not  said  to  have  been  out  of  its  na- 
tural or  ordinary  situation;  on  the  contrary,  it  is  distinctly  stated 
that  the  attendant  was  able  to  pass  a  finger  into,  and  to  determine 
it  was  a  vertex  presentation.  3d.  Because  there  is  no  mention 
made  of  a  tumour  occupying  the  posterior  and  inferior  portion  of 
the  pelvis;  nor  a  single  symptom  to  lead  to  the  suspicion  of  such 
a  case,  even  after  the  ninth  month. 

378.  We  are  told  that  the  patient  had  been  "  weak  and  much 
emaciated;"  but  was  relieved  of  both,  by  the  use  of  stimulants  ; 
is  it  probable  that  stimulants  would  have  improved  the  condi- 
tion of  a  patient  who  was  labouring  under  a  permanent  retrover- 
sion of  the  uterus?  The  only  circumstance  in  the  history  of  this 
case  which  could  lead  to  the  supposition  of  its  being  one  of  re- 
troverted  uterus,  was,  that  Mr.  Penker  found  the  os  uteri  above 
the  symphysis  pubis;  but  this  was  twelve  months  after  labour- 
pains  had  appeared  and  ceased,  and  nearly  as  long  after  the  qui- 
escence, if  not  the  death  of  the  child. 

379.  Again,  Mr.  Penker  speaks  of  iha  jjoste7nor  surface  of  the 
uterus  being  no  thicker  than  a  double  sheet  of  paper.  If  it  were 
a  retroversion  of  the  uterus,  how  could  Mr.  Penker  have  felt  it? 
and  especially  as  this  part  is  represented  to  be  so  much  stretched 
by  the  head  of  the  child.  For  this  part  must  be  behind  the  vagina 
in  a  case  of  retroversion.  Moreover,  he  expressly  states,  that  the 
head  of  the  child  had  descended  very  low  in  the  pelvis,  and  but 
an  inch  and  a  half  from  the  os  externum. 

380.  Were  this  even  admitted  to  be  a  case  of  retroversion,  it 
could  only  have  become  so,  after  the  death  of  the  child,  and  after 
the  belly  had  diminished  in  size.  But  to  put  this  question  to  rest 
at  once,  we  are  told  that  "  the  back  and  feet  of  the  child  could  be 
felt  through  the  abdomen."  Now,  it  is  impossible  that  these 
circumstances  could  obtain,  and  be  a  case  of  retroversion  at  the 


OP  THE  TERM  OF  UTERO-OESTATION.  145 

same  time.  Indeed  we  arc  inclined  to  believe  that  Dr.  Merri- 
man  himself,  in  a  siilisequent  edition  of  his  work,  will  not  select 
this  case,  to  support  his  hypothesis.  See  Essays  on  various 
subjects  connected  with  Midwifery  by  the  author;  in  which  he 
has  ventured  to  offer  strictures,  upon  Dr.  Merriman's  opinion 
upon  this  point,  p.  291. 

381.  Since  the  above  was  written,  we  have  met  with  the  his- 
tory of  a  case,  so  analogous  to  the  one  just  related,  and  w^hich 
dissection  proved  to  be  a  uterine  pregnancy,  as  to  leave  no 
doubts  upon  our  minds,  that  the  case  of  Mr.  Penker  was  one  of 
a  similar  kind.  This  case  is  one  of  great  interest;  inasmuch,  as 
it  shows  the  very  extraordinary  indifference  of  the  uterus  at  times 
to  foreign  bodies  within  its  cavity,  (for  we  must  look  upon  the 
child  and  its  appendages  as  such,  after  they  have  parted  with 
their  vitality,)  after  it  has  made  unsuccessful  attempts  for  their 
removal  at  the  last  period  of  utero-gestation.  We  will  relate 
the  case  as  concisely  as  will  be  consistent  with  its  impor- 
tance. 

382.  Mrs.  A.  H.  aged  twxnty-nine  years,  became  pregnant 
about  the  first  of  April,  1822.  She  was  much  afflicted  at  various 
periods  of  gestation,  with  spasms  of  the  stomach  and  vomiting. 
She  quickened  at  about  the  fourth  month.  After  this  period,  her 
spasms,  &c.  were  less  severe;  but  new  evils  supervened;  such  as 
pains  in  the  hips,  loins,  back,  &c.  About  two  weeks  before  the 
expected  period  of  labour,  she  was  attacked  with  the  usual  symp- 
toms of  this  process.  These  continued  for  ten  hours,  and  then 
subsided;  from  this  time  no  motion  of  the  child  was  felt. 

383.  LS22  "March  1st. — She  was  attacked  with  phlegmasia  alba 
dolens,  in  one  limb.  The  disease  having  left  this  soon  seized 
upon  the  other.  During  the  first  and  second  week  of  this  attack, 
she  had  a  discharge  from  the  vagina,  resembling  the  catamenia. 
At  times  this  was  fetid;  the  os  uteri  was  closed;  no  portion  of 
the  child  could  be  felt.     The  abdomen  very  tense." 

384.  "  About  the  20th  of  March,  she  began  to  recover;  and 
soon  was  able  to  walk  some  distance  without  fatigue.  From  the 
1st  of  April,  convalescence  was  rapid.  The  tumefaction  of  the 
abdomen  began  to  subside;  she  appeared  to  be  as  large  as  at  the 
seventh  month." 

385.  "June  10. — Catamenia;  health  good;  further  subsidence 
of  the  abdomen.    November,  1823. — Nothing  remarkable  occur- 

19 


146  OP  THE  TERM  OP  UTERO-GESTATION. 

red  up  to  this  time.  Abdomen  nearly  to  its  natural  size.  A 
small  tumour  of  the  shape  and  size  of  a  child's  head  remains. 
Two  weeks  after  the  supposed  death  of  the  child,  milk  was 
secreted,  and  continued  in  small  quantities  until  October." 

386.  "April  10th,  1824. — She  was  attacked  with  pain, vomit- 
ing, cough,  &c.  and  continued  in  this  way  until  the  24th  of  May, 
when  she  died." 

387.  Dissection. — "  Upon  opening  the  abdomen,  the  uterus 
was  discovered  to  be  very  much  thickened,  and  presented  the 
appearance  of  having  been  inflamed,  and  to  have  suppurated.  It 
adhered  closely  to  all  the  surrounding  parts,  and  organs.  Anteri- 
orly, it  was  united  intimately  with  the  peritoneum,  and  in  this 
way  with  the  abdominal  parietes.  An  incision  was  made  through 
the  anterior  face  of  the  uterus  and  a  full  grown  fcetus  was  disco- 
vered."   New  England  Journal,  No.  III.  vol.  XIV. 

388.  It  would  be  difficult,  perhaps,  to  find  two  cases  so 
strongly  resembling  each  other  in  most  of  their  leading  and 
material  points,  as  these  just  related;  and  the  latter,  most  satis- 
factorily proves,  that  a  uterine  pregnancy  may  continue  very 
much  beyond  the  ordinary  period  assigned  for  gestation.  In 
this  case,  as  well  as  the  former,  the  material  points  were  sub- 
stantially the  same. 

389.  First.  At  the  usual  period  for  gestation  to  terminate, 
labour  pains  commenced,  and  continued  unavailingly  for  some 
time. 

390.  Second.  In  neither  case  were  the  pains  renewed,  after 
the  first  attempt  was  made  by  the  uterus  to  relieve  itself;  and 
the  motion  of  the  children  ceased  at  about  the  same  period. 

391.  Third.  There  was  a  regular  return  of  the  catamenia  in 
both  instances,  some  time  after  the  cessation  of  pain,  and  in  both, 
an  amendment  of  health  after  this  period,  for  a  certain  duration. 

392.  Fourth.  In  both  instances,  the  abdomen  gradually  dimin- 
ished in  size;  but  in  one,  a  tumour  resembling  in  feeling,  and  in 
size,  a  child's  head,  was  perceived  through  the  abdominal  parie- 
tes; in  the  other  the  back  and  feet  of  the  child  were  to  be  felt. 

393.  Now,  in  the  latter  case,  there  was  full  as  much  reason  for 
considering  it  an  instance  of  extra-uterine  pregnancy,  or  a  retro- 
version continuing  until  full  time,  as  the  other;  and  would  have 
been  so  looked  upon,  perhaps,  by  the  gentleman  who  translated 
the  former  case,  had  not  dissection  settled  the  point. 


CAUSE  OP  LABOUR.  147 

394.  How  the  first  case  may  eventuate  we  can  only  conjec- 
ture; it  may  end  with  safety  to  the  woman,  should  the  uterus  so 
far  regain  its  natural  susceptibilities  and  powers,  as  to  throw  its 
contents  off  per  vias  naturales;  or  inflammation  may  ensue,  and 
the  uterus  discharge  itself  by  ulceration ;  or,  in  case  the  system 
is  not  able  to  institute  this  process,  she  may  die,  like  the  woman 
in  case  second,  of  inflammation,  and  general  irritation  of  the  sys- 
tem. 

395.  In  our  opinion,  these  cases  offer  irrefragable  evidence,  that 
the  uterus  may  remain  quiescent,  for  a  long  period  after  the  ter- 
mination of  the  ninth  month;  and  though  we  acknowledge  them 
both  to  be  extreme  cases,  they  nevertheless  prove  the  fact  con- 
tended for. 


CHAPTER  XI. 

CAUSE  OF  LABOUR. 

396.  Avicenna,  centuries  ago,  declared  that  labour  was  a  law 
of  God,  and  that  it  came  on  at  the  appointed  time.  I  would  ask, 
has  any  hypothesis  since  that  period,  enlightened  us  more  upon 
this  subject,  than  the  humble  confession  of  this  good  old  man? 
Ingenuity  has  attempted  much  upon  this  subject;  but  each  sug- 
gestion has  been  displaced  to  give  room  to  another,  which  like  its 
predecessor  was  to  be  crowded  out  by  some  newer  speculation. 
Thus  Harvey  and  others  supposed  that  the  stirrings  of  the  foetus 
itself  contributed  to  the  production  of  labour,  and  that  it  had 
much  agency  in  its  own  deliverance ;  but  it  had  often  been  proved, 
that  labour  was  sometimes  prematurely  induced  by  the  death  of 
the  foetus;  and  that  in  many  instances,  delivery  was  more  rapid; 
with  a  dead  than  with  a  living  child. 

397.  Others  have  declared,  that  the  desire  of  the  foetus  to  have 
food,  and  to  breathe,  were  the  causes  of  the  first  contractions  of 
the  uterus;  but  the  force  of  both  these  conjectures  are  completely 
destroyed  by  the  argument  just  adduced.  The  liquor  amnii  it 
has  been  said,  becomes  acrid  towards  the  latter  period  of  gesta- 


148  CAUSE  OP  LABOUR. 

tion,  and  by  its  stimulus  forces  the  womb  to  labour.  But,  no 
such  change  in  the  quality  of  this  fluid  has  ever  been  shown;  and 
as  it  cannot  come  in  contact  with  the  immediate  surface  of  the 
uterus,  in  consequence  of  the  interposition  of  the  membranes,  no 
faith  can  be  placed  upon  this  conjecture,  were  it  even  proved, 
that  the  waters  of  the  amnion  had  become  acrid. 

398.  The  explanation  of  Baudelocque  is  very  much  more 
plausible,  and  better  supported.  He  makes  it  consist  in  a  kind 
of  mechanical  necessity;  he  is  of  opinion  that  the  body  and  fun- 
dus by  their  persevering,  alternate  contractions,  especially  after 
the  sixth  month,  oblige  the  neck  of  the  uterus  to  unfold;  and  the 
same  agency,  together  with  the  weight  of  the  child,  constrain 
the  OS  uteri  to  open,  and  labour  to  take  place.  This  hypothesis 
has  some  important  facts  to  sustain  it;  for  the  action  spoken  of, 
really  exists ;  and  after  it  has  commenced,  the  neck  of  the  uterus 
gradually  expands ;  and  is  eventually  obliterated,  and  labour  en- 
sues: but  a  number  of  facts,  in  which  this  change  did  not,  nor 
could  not  take  place,  destroy  much  of  the  force  of  this  ingenious 
suggestion — thus  labour  comes  on  spontaneously  in  some  females 
at  the  seventh,  and  others  at  the  eighth  month  of  pregnancy, 
while  others  abort  at  certain  periods,  without  any  evident  cause. 

399.  The  latest  explanation  we  have  seen,  is  that  of  Mr.  Power, 
which  may  be  looked  upon  as  a  slight  modification  of  that  of 
Baudelocque's;  both  being  strictly  mechanical;  and  the  agent, 
the  wedge.  Mr.  Power  says,*  ''  when  the  state  of  dilatation  has 
proceeded  so  far  that  the  os  uteri  is  opened  to  the  size  of  a  shil- 
ling, or  more,  a  portion  of  the  adjoining  membranes  begin  to  be 
protruded  through  it;  the  effect  of  tb^e  paroxysm  now  impels 
upon  them  a  quantity  of  the  liquor  amnii,  by  which  they  become 
distended  into  a  roundish  tense  bag,  resembling  a  portion  of  a 
blown  bladder,  fdling  up  the  orifice,  and  at  the  same  time,  pressing 
forcibly  upon  it,  on  the  principle  of  a  wedge,  so  as  to  promote 
the  dilatation  ;  this,  which  is  called  the  gathering  of  the  waters, 
is  of  much  utility  in  the  process,  as  instead  of  the  hard  head  of 
the  child,  it  offers  a  soft,  regular,  and  easy  medium,  by  which 
the  dilatation  is  effected.  In  proportion  as  it  advances,  the  size 
of  the  membranous  bag  increases,  until  at  length  the  os  uteri  is 
fully  opened." 

•  'I'reatisc  on  Midwifery,  &,c.  p.  27. 


CAUSE  OF  LABOUR.  149 

400.  We  will  now  examine  this  opinion  a  little  in  detail :  First, 
It  is  stated,  tliat  ^^lohen  the  state  of  dilatation,  has  proceeded 
so  far  that  the  os  uteri  is  ojiened  to  the  size  of  a  shilli7ig,  or 
tnorcy  a  portion  of  the  adjoining  membranes  begin  to  be  pro- 
truded through  it;''  S,'C.  which  membranes  are  eventually,  by 
being  impelled  by  the  contractions  of  the  uterus,  to  effect  the 
complete  dilatation.  Secondly,  that  these  distended  membranes, 
"resembling  a  portion  of  a  blown  bladder,  fdl  up  the  orifice, 
and  at  the  same  time  press  forcibly  upon  it,  '  on  the  principle  of 
the  ivedge,'  so  as  to  promote  the  dilatation."  Third,  It  is  de- 
clared, that  the  os  uteri  is  filled  up  by  the  distended  membranes. 

401.  It  is  evident  at  first  sight,  that  the  scheme  proposed  by 
Mr.  Power,  for  the  dilcitation  of  the  os  uteri,  requires  the  agency 
of  two  distinct  and  widely  differing  powers  for  its  completion, 
(though  he  acknowledges  but  one;)  namely,  one,  which  shall  open 
the  orifice  "to  the  size  of  a  shilling,  or  77iore;"  and  a  second, 
(which  is  entirely  mechanical,)  to  complete  the  expansion;  the 
latter  consists  of  the  distended  membranes,  which  are  to  enter  the 
os  uteri  on  the  principle  of  the  wedge,  and  so  promote  the  dilata- 
tion. 

402.  Now,  from  all  that  Mr.  Power  says  after  this  exposition, 
of  the  manner  in  which  the  os  uteri  becomes  expanded,  it  is  evi- 
dent he  intended,  that  a  mechanical  power  should  be  considered 
as  the  sole,  and  efficient  cause,  of  this  phenomenon.  This  being 
the  case,  we  would  inquire,  by  what  influence  or  power,  was  the 
OS  uteri  first  dilated  to  ''the  size  of  a  shilling,  or  tnoreV  It 
could  not  have  been  by  the  distended  membranes;  for  Mr.  P.  de- 
clares that  this  does  not  take  place  until  after  this  degree  of  open- 
ing has  been  effected. 

403.  Is  it  not  then  probable,  that  the  uterus  possesses  some 
organic  power  by  which  it  effects  the  opening  of  the  os  uteri,  and 
which  is  totally  independent  of  the  mechanical  influence  of  the 
distended  membranes,  since,  a  certain  degree  of  dilatation  takes 
place,  without  their  agency?  And  if  this  be  true  in  part,  as  is 
admitted  by  Mr.  P.,  may  it  not  be  capable  of  effecting  the  entire 
expansion  of  this  part?  we  certainly  think  so;  and  in  our  chapter 
"On  Labour,"  in  the  section,  treating  of  the  manner  in  which 
the  03  uteri  becomes  opened,  we  have  given  our  viev.'s  upon  this 
subject,  and  to  which  we  beg  to  refer  the  reader. 

404.  Indeed,  Mr.  P.  himself,  immediately  after  declaring  the 
necessity  and  eflicicncy  of  the  distended  ijiembranes  to  produce 


150  CAUSE  OF  LABOUR. 

the  dilatation  of  the  os  uteri,  goes  on  to  say,  "in  proportion  as 
it  advances,  (the  dilatation  of  the  os  uteri,)  the  size  of  the  mem- 
branous bag  increases,  until  at  length  the  os  uteri  is  fully  open- 
ed." By  this  admission,  the  order  of  cause  and  effect  are  re- 
versed; above,  we  are  told  that  the  distended  membranes  enter 
the  OS  uteri  after  it  is  opened  to  the  size  of  a  shilling,  or  more, 
and  on  the  principle  of  a  wedge,  effect  its  enlargement;  imme- 
diately below  we  are  informed,  that  the  size  of  the  membranous 
bag  increases  in  proportion  to  the  dilatation  of  the  os  uteri. 

405.  In  the  first  instance,  the  extent  of  dilatation  of  the  os 
uteri  is  in  proportion  to  the  size  of  "  the  roundish  tense  bag;" 
in  the  next,  the  size  of  the  membranous  bag,  is  commensurate 
with  the  expansion  of  the  mouth  of  the  uterus;  now  the  mem- 
branous bag  cannot  be  both  active  and  passive  at  the  same 
instant. 

406.  Besides,  Mr.  P.  makes  the  uterus  perform  a  work  of  su- 
pererogation in  effecting  the  opening  of  its  mouth.  For  agreeably 
to  him,  as  we  have  shown  above,  the  active  agent  in  the  produc- 
tion of  this  effect,  is  the  mechanical  influence  of  the  distended 
membranes  against  the  orifice  of  the  womb  in  the  time  of  pain; 
yet  he  informs  us  with  a  commendable  candour,  though  not  in- 
tended as  a  concession,  "that  as  the  paroxysm  comes  on,  the  ori- 
fice begins  to  acquire  a  tense  and  constricted  feel,  its  internal  rim 
becomes  more  perfectly  circular,  fixed  and  incapable  of  being 
moved  laterally  by  the  action  of  the  finger."  It  is  evident,  there- 
fore, if  Mr.  P.'s  explanation  be  the  true  one,  that  nature  is  at 
variance  with  herself;  a  circumstance  that  very  few  will  admit, 
when  she  is  performing  the  ordinary  functions  of  the  system, 

407.  Agreeably  to  this  scheme,  the  fundus  and  body  of  the 
uterus  contract  with  the  effect  of  pressing  the  presenting  part 
against  the  orificium  uteri,  that  it  may  be  expanded  sufficiently  to 
permit  the  child  to  pass;  but  this  intention  is  effectually  frustrated 
by  the  perverseness  of  the  os  uteri.  For  instead  of  yielding  kindly 
to  the  impulse  of  the  fundus  and  body,  as  we  suppose  it  should  do 
under  such  circumstances,  it  opposes  their  efforts,  by  becoming 
tense,  and  constricted,  and  thus,  at  once  defeating  the  very  object 
of  the  "  parturient  paroxysm."  Now,  we  admit,  that  this  really 
does  take  place;  that  it  is  continued  for  some  time;  and  that  it  is 
attended  by  these  very  circumstances.  But  after  a  longer  or 
shorter  time,  the  orifice  of  the  uterus  is  found  dilated,  and  this 


CAUSE  OF  LABOUR.  151 

without  the  mechanical  aid  of  the  distended  membranes;  for  un- 
der the  best  condition  of  this  part  it  is  found  fully  expanded  with- 
out the  membranous  bag  (however  tense  this  may  be)  engaging 
in  its  circle;  consequently,  witliout  its  being  directly,  and  physi- 
cally acting  within  this  circle,  like  a  wedge. 

408.  It  must  be  evident,  if  the  distended  membranes  are  to  act 
upon  the  principle  of  the  wedge,  they  must  be,  for  this  purpose, 
in  complete  possession  of  the  uterine  circle;  and  if  placed  thus, 
they  must,  (caeteris  paribus,)  stretch  it  quaqua  versum,  and  thus 
tend  to  thicken  the  edges,  by  making  them  encroach  upon  the 
portions  of  the  neck  of  the  uterus,  not  dilated;  but  this  never,  or 
but  very  rarely,  takes  place.*  Now  it  is  familiarly  known  to 
almost  every  obstetric  practitioner,  that  when  the  os  uteri  is  about 
to  yield  in  its  kindest  manner,  that  nearly  the  whole  of  that  por- 
tion, which,  in  the  unimpregnated  state  constitutes  the  neck,  be- 
comes by  the  continuance  of  labour,  thinner  and  thinner;  and  es- 
pecially at  that  part  which  constitutes  its  mouth,  until  at  last  it 
becomes  so  attenuated,  and,  as  it  were,  so  paralyzed,  that  it  dis- 
continues its  opposition,  and  fully  dilates  itself;  and  all  this  hap- 
pens without  the  agency  of  the  membranes;  or,  (if  they  be  rup- 
tured,) the  presenting  part  engaging  in  the  circle  of  its  retiring 
edges ;  unless  it  be  after  the  os  uteri  has  become  fully  dilated.t 

409.  Again,  Mr,  P.  tells  us,  that  the  "parturient  paroxysm" 
obliges  the  presenting  part  to  approach  nearer  to  the  external 
orifice,  with  a  degree  of  force  which  the  finger  is  incapable  of 
resisting,  and  by  which  the  orifice  is  often  seyisibly  enlarged. 
A  few  lines  above,  and  in  the  same  paragraph,  he  declares,  as  we 
have  just  stated,  that  this  part,  in  consequence  of  the  paroxysm, 
"acquires  a  tense  and  constricted  feel,  its  rim  becomes  more  per- 

•  See  Chapter  "On Labour." 

f  That  is,  agreeably  to  our  view  of  the  subject,  the  circular  fibres  of  the  neck 
and  mouth  of  the  uterus,  relax  themselves,  by  a  law  of  the  uterus;  and  thus 
give  to  the  longitudinal  fibres  the  control:  for  by  the  conti-action  of  the  latter, 
the  uterus  becomes  shorter,  and  consequently  will  widen  itself  at  its  opening, 
by  drawing  the  circidar  fibres  upwards.  When  this  happens,  the  mouth  of  the 
uterus  is  drawn,  or  has  a  tendency  to  be  drawn  upwards,  and  the  presenting  part 
escapes  from  it — hence,  after  the  complete  expansion  of  the  os  uteri,  its  margin 
is  often  not  to  be  found;  but  when  it  is  not  retracted,  it  advances  before  the  head 
of  the  child;  and  though  every  way  disposed  to  dilate  fully,  or  yield  to  the  pass- 
ing head,  it  often  remains  in  that  situation,  so  as  to  become  a  cause  of  tedious  or 
difficult  labour.     Sec  chapter  on  Tedious  Labour. 


152  €AUSE  OP  LABOUR. 

fectly  circular,  fixed,  and  incapable  of  being  moved  laterally  by 
the  action  of  the  finger." 

410.  Notwithstanding  these  declarations,  Mr.  P.  will  have  us 
believe,  that  the  (generally)  frail  membranes,  will  overcome  a  re- 
sistance, which  the  united  efforts  of  the  body  and  fundus,  and  an 
introduced  finger  is  incapable  of;  for  the  membranes  efiect 
agreeably  to  him,  the  dilatation  of  the  os  uteri  by  their  presence 
within  its  circle.  Now,  it  must  be  evident,  that  they  cannot  do 
this,  even  according  to  his  own  showing,  without  exerting  a  force 
upon  the  uterine  mouth,  superior  to  the  resistance  with  which 
this  part  maintains  its  contraction;  and  this  is  acknowledged  by 
him  to  be  more  than  equal  to  any  degree  of  force,  that  the  finger 
could  exert  in  order  to  move  it  laterally.*  Is  it  for  a  moment  to 
be  believed,  that  these  membranes  can  exert  such  a  degree  of 
force?  But  to  put  this  subject  at  rest;  we  have  attempted  to 
show,  in  the  section  above  referred  to,  that  the  most  entire  dila- 
tation of  the  OS  uteri  takes  place,  without  the  intervention  of  the 
distended  membranes,  or  even  of  the  presenting  part.  And  Mr. 
P.  must  have  met  with  similar  cases,  in  his  own  practice. 

411.  Having  premised  the  above  explanation,  and  the  eSect  of 
the  "expulsive  or  parturient  action,"  Mr.  P.  proceeds  to  the  con- 
sideration of  the  nature  and  cause  of  the  parturient  action." 
Under  this  head,  Mr.  P.  offers  a  new,  and  certainly,  an  ingenious 
hypothesis:  which  it  becomes  our  duty  to  examine,  lest  it  be  too 
easily  admitted  as  true. 

412.  Mr.  P.  commences  his  subject,  by  an  unnecessary  endea- 
vour to  prove  the  muscularity  of  the  uterus,  and  that  its  action 
is  similar  to  that  of  other  muscles.  He  next  informs  us,  that  this 
organ  is  liberally  supplied  with  nerves  from  several  sources;  and, 
that  the  neck  of  the  uterus  is,  in  an  especial  manner,  furnished 
with  them;  and  hence  the  great  sensibility,  upon  which  he  grounds 
his  hypothesis. 

413.  He  declares  the  uterus  to  be  disposed  to  expel  its  contents 
during  the  whole  term  of  utero-gestation,  whenever  a  sufficient 

»  We  are  not  certain  that  we  liave  arrived  at  tlie  exact  meaning-  of  the  word 
"laterally,"  as  employed  by  Mr.  P.  We  presume,  however,  that  he  intends 
to  convey  the  idea,  that  the  os  uteri  cannot  be  stretched  by  an  introduced  finger 
in  that  direction,  during  the  "partiment  paroxysm,"  or,  in  other  words,  that  at 
this  time  it  maintains  its  "constriction"  with  iin  obstinacy,  that  is  not  to  be  sub- 
dued by  any  safe  degree  of  force,  tliat  could  be  applied  by  the  finger. 


CAUSE  OF  LABOUR.  153 

exciting  cause  is  applied;  and  that  this  disposition  is  inherent,  and 
not  adventitiously  acquired  during  pregnancy.  He  then  asks, 
"what  is  then  the  nature  of  that  exciting  cause,  which  in  partu- 
rition determines  the  uterine  muscles  to  these  efforts  at  so  exact 
a  period?"  p.  33.  He  contends  that  '<  the  exciting  cause,  al- 
though acting  upon  the  susceptibility  of  the  uterus  to  receive  its 
impressions,  does  not  appear  innate  in  the  uterus  itself,  but  pro- 
bably consists  of  some  principle,  externally  or  mechanically  ap- 
plied to  it."  p.  34. 

414.  He  attempts  to  support  these  opinions,  by  ingeniously  em- 
ploying analogies  furnished  by  the  actions  of  the  rectum  and 
bladder;  and  being  thus  strengthened,  as  he  believes,  he  pro- 
ceeds to  a  more  detailed  exposition  of  the  modus  operandi  of 
the  causes  which  act  upon  these  peculiar  susceptibilities  of  the 
uterus. 

415.  ''  It  has  been  observed,  that  a  regular  series  of  change 
takes  place  in  the  cervix  of  the  uterus  during  the  latter  months, 
which  only  becomes  completed  at  the  end  of  gestation,  and  im- 
mediately before  the  commencement  of  parturition.  This  change 
has  been  stated  to  consist  of  a  gradual  opening,  or  expansion  of 
the  cervix  ;  during  the  earlier  parts  of  gestation,  tlie  uterine  con- 
tents are  at  a  distance  from  its  orifice;  but,  as  the  expansion  pro- 
ceeds, they  gradually  approximate;  when  it  is  completed,  they  are 
contiguous,  and  the  process  of  expulsion  soon  succeeds.  A  strong 
analogy  may  be  here  observed,  with  the  case  of  fajcal  evacuation, 
in  which  a  gradual  progress  takes  place  of  the  faecal  contents  to- 
wards the  sphincter,  and  in  which  also  the  ready  disposition  to 
contract,  is  proportionate  to  that  progress ;  and  is  most  perfect 
w^hen  they  are  contiguous."  In  order  to  understand  this  analogy, 
we  must  relate  Mr.  P.'s  notions  of  this  act.  He  considers  the 
rectum  as  a  mere  receptacle  for  the  fasces,  with  which  it  becomes 
gradually  filled;  "the  first  portions  of  which  enter  the  rectum, 
and  occupy  the  farthest  extremity,"  (that  is,  the  upper  portion 
of  this  gut,)  « but  as  each  successive  portion  is  received,  the 
former  one  is  protruded  forward  by  the  impulse  from  behind, 
assisted  by  the  contractile  power  of  the  part,  until  it  eventually 
arrives  at  the  anterior  extremity  or  sphincter;  in  proportion,  as 
the  accumulation  takes  place  at  this  point,  a  stimulating  effect  is 
produced  upon  it,  the  irritation  of  which  is  at  length  followed  by 

20 


154  CAUSE  OF  LBOUR. 

the  action  of  the  muscular  coat  of  the  rectum,  which  presses  for- 
cibly upon  the  faiccs,  and  expels  them."  p.  34. 

41().  Between  the  illustration  just  given,  and  the  exciting  cause 
of  labour  as  stated  by  Mr,  P.,  we  do  not  perceive  the  slightest 
analogy;  nor  can  any  exist  if  Mr.  P.'s  explanation  be  right,  and 
for  the  following  reasons:  First,  Because  the  relaxation  of  the 
sphincter  ani  which  precedes  the  expulsion  of  the  faeces,  is  an  act 
of  the  will;  for,  from  the  constant  tendency  of  the  rectum  to  be- 
come distended,  it  requires,  that  the  excrementitious  part  of  the 
food  should  be  occasionally  carried  off;  and  this  is  done  when- 
ever the  rectum  is  filled;  for  the  irritation  occasioned  by  its  dis- 
tention advertises  the  individual  of  the  necessity  of  its  being 
emptied;  he  wills  that  this  should  take  place;  in  obedience  to 
which,  the  sphincter  ani  is  relaxed ;  the  effect  of  expulsion  fol- 
lows; and  the  rectum  is  relieved  of  its  contents.* 

417.  Secondly,  Because  Mr.  P.  makes  the  opening  of  the  os 
uteri  to  depend  upon  mechanical  force,  whereas  the  sphincter 
ani  requires  no  such  force,  to  call  the  auxiliary  powers  concern- 
ed in  the  discharge  of  the  faices,  into  action.  The  "  irritation" 
which  calls  the  attention  of  the  will,  (if  we  may  so  term  it,)  to 
this  act,  does  not  necessarily  i^eside  in  the  rectum ;  or  rather  on 
the  verge  of  the  sphincter  ani ;  for  it  is  often  seated  in  the  sto- 
mach, more  frequently  in  the  bowels,  and  sometimes  only  in  the 
imagination. 

418.  Thirdly,  Because,  we  do  not  fmdthis  "  irritation"  always 
produced,  by  the  presence  of  a  large  quantity,  of  even  indurated, 
(and  as  it  would  seem  more  highly  stimulating  from  their  me- 
chanical properties,)  fasces ;  as  in  constipation. 

419.  Fourthly,  Because,  some  of  the  most  violent,  tormenting, 
and  frequent  discharges  from  the  rectum,  are  not  caused  by  the 

*  It  is  true  that  the  relaxation  of  the  sphincter  ani  is  not  always  in  obedience 
to  the  will;  and  may,  when  this  happens,  be  considered  as  mihtating  against 
this  objection;  but  this  it  surely  does  not  do,  under  the  point  of  view  this  sub- 
ject is  examined — for  when  involuntarily  discharges  take  jilace,  the  parts  both 
directly  and  indirectly  concerned  in  the  operation,  are  labouring  under  disease: 
consequently,  must  not  be  looked  upon  as  illustrative  of  a  healtliy  or  normal 
action.  The  brain  may  be  so  disordered,  that  the  will  cannot  act;  or  the 
sphincter  may  be  somorl)idly  irritable,  as  not  to  be  under  its  control;  or  the 
actions  associated  with  the  irritations  of  the  rectum  may  be  so  susceptible  of 
impressions  as  to  force  the  sphincter  to  obedience. 


CAUSE  OF  LABOUR.  155 

presence  of  faeces  in  this  gut;  as  in  tenesmus,  or  dysentery;  nor 
is  distention  necessary  always  to  the  relaxation  of  the  sphincter 
ani;  as  we  see  in  diarrhoea. 

420.  Fifthly,  Because,  Mr.  P.  makes  the  opening  of  the  os 
uteri  to  consist  in  a  mechanical  stretching;  but  the  opening  of 
the  sphincter  ani,  is  a  functional  act;  namely,  the  relaxation  of  a 
muscular  band,  and  subject  to  the  control  of  tlie  will. 

421.  Sixthly,  Because,  Mr.  P.  confesses  that  there  is  a  con- 
sciousness of  the  presence  of  some  irritating  substance  applied 
to  the  sphincter;  for,  he  says,  "that  during  the  earlier  periods  of 
accumulation,  no  disposition  to  expulsion  is  perceived ;  and  in 
the  latter  period,  when  the  sensation  of  want  of  expulsion  comes 
on,  it  is  always  referred  to  the  sphincter."  Now,  it  is  known  to 
everybody,  that  at  neither  the  commencement  of  labour,  nor  dur- 
ing any  period  of  its  progress,  is  any  sensation  experienced  at  the 
sphincter  of  the  uterus;  nor  can  any  woman  will  its  relaxation  or 
contraction. 

422.  The  same  arguments  may  be  employed  against  his  other 
analogy;  namely,  the  filling  of  the  bladder,  and  the  extrusion  of 
the  urine,  as  it  is  founded  upon  the  same  principle,  and  derives 
support  from  similar  phenomena. 

423.  Having  first  given  Mr.  P.'s  views  of  the  manner  in  which 
the  OS  uteri  becomes  expanded,  we  will  proceed  to  examine  the 
principles  on  which  he  predicates,  "  the  nature  and  cause  of  par- 
turient action." 

424.  Mr.  P.  after  briefly  relating  the  order  of  changes  in  the 
developement  of  the  uterus,  up  to  the  commencement  of  parturi- 
tion, says,  "during  the  earlier  months  of  pregnancy,  the  uterine 
contents  are  at  a  distance  from  its  orifice;  as  the  expansion  pro- 
ceeds, they  gradually  approximate;  when  it  is  completed  they 
are  contiguous,  and  the  process  of  expulsion  soon  succeeds.  A 
strong  analogy  may  be  here  observed  with  the  case  of  faecal 
evacuation  just  noticed,  in  which  a  gradual  progress  takes  place 
of  the  faecal  contents  towards  the  sphincter,  and  in  which  also 
the  ready  disposition  to  contract,  is  proportionate  to  that  pro- 
gress; as  is  most  perfect  when  they  are  contiguous;  but  the  ana- 
logy does  not  rest  here,  as  it  may  be  shown  that  the  nervous 
structure  connected  with  their  respective  organs,  are  not  only 
similar,  but  derived  from  the  same  origin,  both  being  supplied 
with  nerves  from  the  hypogastric  trunk,  of  which  one  division 


156  CAUSE  OF  LABOUR. 

is  expended  upon  the  rectum  and  its  sphincter,  the  other  upon 
the  uterus,  and  vagina.  Is  it  not  reasonable  to  suppose  this 
similarity  of  structure  to  be  attended  with  similarity  of  action, 
particularly  when  we  do  know,  that  their  functions  are,  corres- 
pondent, viz.  to  exclude  the  contents  of  their  respective  or- 
gans.^" 

425.  <' We  have  hence  strong  analogy  to  prove  that  the  con- 
tractions of  the  uterus  are  produced,  in  consequence  of  a  certain 
impression  excited  by  its  contents  upon  its  orifice.  We  shall  in- 
quire how  far  circumstances,  connected  with  the  structure  and 
actions  of  the  uterus,  confirm  the  position." 

426.  ''It  has  been  admitted  that  different  parts  of  the  uterus 
are  possessed  of  different  states  of  sensibility,  and  that  its  orifice 
is  most  highly  charged;  upon  whatever  ground  the  admission 
has  been  founded,  it  is  confirmed  and  illustrated  by  anatomical 
observation.  We  have  seen  it  supplied  with  nerves  from  the 
renal  plexus,  the  spermatics,  and  the  hypogastric  nerves;  the 
two  former,  which  are  chiefly  derived  from  the  sympathetic 
plexus,  supply  the  upper  parts  of  the  uterus,  ovaria,  &c.  and 
may  be  considered  as  the  chief  media  of  their  communications 
with  the  general  system,  or  of  their  sympathetic  actions;  the 
latter,  though  not  devoid  of  connection  with  the  sympathetic 
nerves,  is  principally  formed  from  the  spinal  nerves,  which  are 
more  peculiarl}'  nerves  of  motion;  it  may  be  considered  the 
chief  nerve  of  the  uterus  and  vagina,  upon  every  part  of  which 
the  largest  part  of  it  is  expended,  the  lesser  one,  as  before  noticed, 
supplying  the  rectum;  it,  however  passes  more  directly  and 
largely  to  the  os  tinea;  and  adjoining  parts." 

427.  "It  may  hence  be  inferred,  that  the  orifice  of  the  uterus 
possesses  a  high  state  of  nervous  power,  and  consequently  a  pe- 
culiar function.  It  has  also  been  observed  that  this  part  becomes 
little  connected  with  utero-gestation  until  that  oflice  is  complete, 
being  previously  removed  to  a  determinate  distance  from  the 
distending  process.  Is  it  not,  therefore,  reasonable  to  consider 
that  its  peculiar  function,  so  far  as  it  is  connected  with  a  high 
state  of  sensibility,  is  to  give  warning  of  the  task  of  utero-gesta- 
tion being  performed,  and  to  be  the  medium  of  calling  into  ac- 
tion, the  powers  which  are  appointed  to  produce  the  expulsion  of 
the  now  mature  foetus?"  p.  36,  &c. 

428.  From  wjjat  has  been  just  said,  it  appears  that  Mr.  P.  in- 


CAUSE  or  LABOUR.  157 

sists  upon  the  following  positions  or  principles,  as  essential  to  the 
establishment  of  his  hypothesis. 

429.  First,  That  the  uterus  is  gradually  developed;  but  not 
completely,  until  the  last  period  of  utero-gestation;  that  is,  the 
neck  of  this  organ  is  not  effaced  until  that  epoch. 

430.  Secondly,  That  the  design  of  this  arrangement  is  to  keep 
the  uterine  contents  at  a  distance  from  the  os  tincae. 

431.  Thirdly,  That  as  gestation  advances,  the  contents  of  the 
uterus,  and  the  os  tincae  gradually  approximate ;  when  completed 
they  are  in  contact. 

432.  Fourthly,  That  there  is  a  strong  resemblance  of  nervous 
structure  between  the  uterus  and  rectum.  And  that  this  corres- 
pondence in  structure  is  to  ensure  a  similarity  of  function  ;  name- 
ly, to  "  exclude  the  contents  of  their  respective  organs." 

433.  Fifthly,  That  the  contractions  of  the  uterus  ai-e  produced, 
in  consequence  of  a  certain  impression  excited  by  its  contents 
upon  its  orifice. 

434.  Sixthly,  That  the  different  parts  of  the  uterus  "are  pos- 
sessed of  different  states  of  sensibility,  and  that  its  orifice  is  most 
highly  charged." 

435.  Seventhly,  That  as  the  orifice  of  the  uterus  possesses  a 
high  state  of  nervous  power,  it  must  necessarily  have  a  peculiar 
function. 

436.  Eighthly,  That  the  os  uteri  is  but  little  connected  with 
utero-gestation,  until  this  is  nearly  completed,  as  the  contents  of 
the  uterus  are  designedly  removed  from  it. 

437.  Ninthly,  That  the  os  uteri,  from  its  great  sensibility,  is  in- 
tended to  give  notice,  that  the  term  of  utero-gestation  is  com- 
pleted; and  is  the  medium  by  which  the  fundus  and  body  are 
called  into  action,  that  the  foetus  may  be  expelled. 

438.  Tenthly,  That  in  proportion  to  the  pressure  exerted  by  the 
uterine  contents  upon  the  os  uteri,  will  be  the  efficiency  of  the 
"  parturient  action,"  as  is  illustrated  by  malposition,  &c.  &c. 

439.  Eleventhly,  That  the  cessation  of  contraction,  in  cases  of 
ruptured  uteri,  is  owing  to  the  removal  of  the  presenting  part 
from  the  os  uteri. 

440.  We  trust  we  have  faithfully  given  Mr.  P.'s  ideas  on  the 
subject  in  question,  in  the  positions  now  laid  down;  we  will  there- 
fore proceed  in  order  to  their  examination. 


158  CAUSE  OF  LABOUR. 

441.  To  positions  first  and  second,  we  would  observe,  that 
though  they  are  strictly  true  as  regards  arrangement,  yet  that  this 
arrangement  is  not  for  the  purposes  declared  by  Mr.  P. ;  namely, 
that  the  uterine  contents  should  be  kept  at  a  distance  from  the 
highly  sensible  os  uteri,  that  the  parturient  action  need  not  be  pro- 
voked.    See  prop,  sixth. 

442.  Now,  it  is  a  fact  known  to  everybody,  that  the  complete 
distension  of  the  uterus  is  not  essential  to  this  end;  since  the  ute- 
rus occasionally  expels  its  contents  at  every  period  of  gestation, 
from  a  variety  of  causes,  which  cannot  in  possibility  act  upon  the 
sensitive  os  tincse  as  a  mechanical  irritant.  The  ergot  has  been 
known  to  produce  abortion,  as  well  as  other  substances;  so  have 
passions  and  emotions  of  the  mind;  as  well  as  external  mechani- 
cal injuries,  as  blows,  falls,  &:c. 

443.  In  neither  of  these  instances  was  it  essential  to  the  pro- 
duction of  the  parturient  effort,  that  the  uterus  should  have  been 
fully  developed,  or  that  the  os  uteri  should  have  been  irritated  by 
the  presence  of  the  foetus  or  embryo,  (see  prop,  fifth  and  tenth;) 
yet  the  uterine  contents  were  thrown  off  by  the  repeated  contrac- 
tion of  the  fundus  and  body. 

444.  To  proposition  third,  we  may  remark,  that  it  proves  no- 
thing, unless  it  can  be  shown,  that  the  sensibility  included  in  prop, 
sixth,  is  exclusively  resident  in  the  extreme  external  edge  of  the 
os  tincse;  for,  if  it  be  admitted  that  the  nervous  distribution  is  ex- 
tended over  the  whole  of  the  neck  of  the  uterus,  (as  is  confirmed 
by  anatomy,)  premature  labour  should  always  take  place  so  soon 
as  this  part  is  called  upon  to  furnish  room  for  the  augmenting  size 
of  the  foetus. 

445.  For  immediately  after  the  sixth  month,  the  neck  of  the 
uterus  is  found  to  expand;  and  it  continues  to  do  so,  until  it  is  en- 
tirely effaced.  If,  then,  the  "  parturient  action"  depend  upon  the 
application  of  the  contents  of  the  uterus  to  this  highly  sensible 
2}art,  (according  to  Mr.  P.)  namely,  the  neck  of  the  uterus,  why 
is  not  its  sensibility  so  roused  by  this  mechanical  impression,  as 
to  call  into  action  the  parturient  effort,  and  premature  delivery 
take  place?  But  we  find  it  altogether  otherwise  in  the  ordinary 
arrangement  of  nature:  for  it  is  almost  constantly  found  that  the 
neck  of  the  uterus  passively  suffers  itself  to  be  developed,  to  the 
last  period  of  utero-gestation,  without  manifesting  the  slightest 


CAUSE  OF  LABOUR.  159 

repugnance  to  the  operation ;  it  must,  therefore,  be  evident,  tliat 
it  would  1)6  otherwise,  were  Mr.  P.'s  hypothesis  well  sustained, 
since  here  the  agent  and  capacity  are  constantly  presented  to  each 
other.* 

446.  To  proposition  fourth,  it  is  scarcely  necessary  to  reply, 
since  it  also  proves  nothing.  The  stomach,  the  oesophagus,  the 
alimentary  canal,  the  gall-bladder,  the  vesiculse  seminalis  and  pe- 
nis in  the  male,  the  vagina,  all  have  muscular  fibres,  elastic  mem- 
branes, blood-vessels,  nerves,  &c.  like  the  uterus:  yet  they  prove 
nothing,  by  their  structure,  in  favour  of  the  position  of  Mr.  P. 
that  the  contractile  powers  of  the  body  and  fundus  are  called  into 
action,  as  an  original  and  natural  function,  in  consequence,  and 
by  necessity  of,  an  irritation  produced  on  the  mouth  of  the  uterus, 
by  the  pressure  of  the  contents  of  this  organ,  as  declared  in  prop, 
fifth. 

447.  To  proposition  fifth,  we  must  declare,  that  it  is  not  sus- 
tained by  any  fact  within  our  knowledge,  as  a  natural  and  essen- 
tial arrangement.  It  would  necessarily  require  that  the  extreme 
sensibility  of  the  neck  of  the  uterus  should  be  confined  to  the  ex- 
treme edge  of  the  os  tincae;  [see  answer  to  prop,  third,]  or  that 
that  portion  of  this  organ,  which,  in  its  vacant  state,  as  well  as 
in  a  state  of  impregnation  until  the  sixth  month,  called  its  neck, 
must  acquire  a  new  state  of  sensibility,  the  instant  the  full  term 
of  gestation  is  completed;  which  condition  has  neither  been 
shown  nor  insisted  on  by  Mr.  P.  For,  if  the  whole  neck  were 
possessed  of  an  equal  degree  of  sensibility,  premature  labour 
must  lake  place  soon  after  the  sixth  month,  agreeably  to  the 
scheme  of  Mr.  P.;  since  it  is  acknowledged  by  all  accoucheurs 
of  experience,  that  there  is  a  constant  nisus  in  the  body  and 
fundus;  and  which  is  favourable  to  the  expansion  of  the  neck, 
(par.  206.) 


•  Mr.  Power  says,  rather  incorrectly,  we  think,  that  the  "  orifice  of  the  uterus 
is  but  httle  connected  with  utcro-gestation,  until  that  office,  (of  utero-g-estation,) 
is  complete;"  [prop,  eighth,]  as  we  know  that  it  must  necessarily  be  involved 
in  the  developement  of  the  neck,  so  soon  as  tliis  pai-t  is  acted  upon  by  the  con- 
tractions of  the  body  and  fundus,  as  just  stated.  And  if  he  shall  insist,  that 
"the  higli  state  of  nervous  power,"  is  confined  to  the  mai-ginof  the  opening  of 
the  uterus,  lie  is  bound  to  show  some  proof  of  it ;  for  so  far  he  certainly  has  not. 
A  bare  assertion  to  tliis  eflcct  is  not  sufficient. 


160  CAUSE  OP  LABOUR. 

448.  This  being  the  case,  it  must  be  evident  that  the  neck 
will  be  more  or  less  irritated,  (if  it  possessed  this  extreme  sen- 
sibility^ by  the  contents  of  the  uterus  being  forced  constantly 
against  it,  by  the  contractions  of  the  body  and  fundus;  and,  which 
we  believe  invariably  takes  place,  at,  or  very  soon  after,  the 
sixth  month. 

449.  Besides,  we  have  no  evidence  of  the  "high  state  of  sen- 
sibility," spoken  of  in  prop,  sixth,  by  Mr.  P.  It  certainly  docs 
not  exist  agreeably  to  our  experience,  either  before  or  during 
parturition  as  a  natural  condition  of  this  part;  for  unless  it  be  in 
a  state  of  disease,  either  chronic  or  immediately  produced  by 
rude  and  improper  management,  we  have  no  evidence  of  this 
state.  We  can  with  much  safety  say,  we  have  touched  the  os 
uteri  a  thousand  times,  without  the  woman  betraying  the  slight- 
est inconvenience  or  pain. 

450.  To  prop,  seventh,  we  can  only  say,  that  were  this  "high 
state  of  nervous  power"  admitted  to  exist,  it  would  prove  no- 
thing in  favour  of  Mr.  P.'s  hypothesis,  unless  he  can  prove  that 
the  mouth  of  the  uterus  always  obtains  it  at  the  moment  that 
utero-gestation  is  finished.  For  if  he  cannot  do  this,  and  he 
insist,  that  it  takes  place  during  the  progress  of  gestation,  it 
would  be  certainly  mischievous;  as  it  must  be  acted  upon 
very  constantly  by  a  variety  of  agents;  and  thus  would  "  give 
warning  of  the  task  of  utero-gestation  being  perfected,"  and 
that  labour  was  about  to  ensue  prematurely. 

451.  In  prop,  eighth,  Mr.  P.  seems  aware  of  the  difficulty  there 
would  be  to  reconcile  "  this  high  state  of  sensibility"  of  the  orifice 
of  the  uterus,  with  the  unavoidable  production  of  irritation  from 
the  presenting  part,  (did  this  condition  really  exist,)  as  gesta- 
tion advances,  and  especially  after  the  sixth  month.  He  therefore 
relies  for  support  upon  the  mechanical  arrangement,  mentioned 
in  one  part  of  the  proposition  under  consideration,  by  saying, 
that  the  orifice  is  "  removed  at  a  distance  'from  the  distending 
process."  Now  it  must  be  well  known  to  so  experienced  a  prac- 
titioner as  Mr.  P.  that  labour  ensues  sometimes  before  the  entire 
obliteration  of  the  neck  takes  place;  and  that  it  does  not  neces- 
sarily ensue  immediately  after  it  is  completely  effaced;  neither 
of  which  should  happen  in  anything  like  the  frequency,  that 
we  have  occasion  to  observe  it,  were  Mr.  P.'s  hypothesis  well 
founded.    Nay,  the  mouth  of  the  uterus  will  sometimes  be  opened 


CAUSE  OF  LABOUR.  161 

to  some  extent  for  days:  indeed,  even  weeks  now  and  then,  with- 
out the  "parturient  eflbrt"  declaring  itself.* 

452.  The  ninth  proposition  declares,  that  the  great  sensibility 
of  the  OS  uteri  is  intended  to  notify  the  other  portions  of  this  or- 
gan, that  the  great  business  of  gestation  is  fmished;  and  that  they 
must  now  set  into  action  the  parturient  powers  to  remove  the 
product  of  this  elaborate  process.  It  must  of  necessity  follow, 
that  this  high  state  of  sensibility  is  a  sine  qua  non  to  parturition; 
and  that  the  entire  developement  of  this  portion  of  the  uterus  is  a 
sine  qua  non  to  this  sensibility;  since  Mr.  P.  affirms  that  this  part 
is  but  little  connected  with  utero-gestation  until  this  office  is 
complete,  [prop,  eight.]  The  facts  detailed  in  the  observations 
upon  prop,  eight,  may  be  successfully  employed  against  these 
views. 

453.  Besides,  it  is  well  known  that  labour  comes  on  as  prompt- 
ly, and  as  certainly,  when  the  foetus  dies  before  its  full  develope- 
ment, and  consequently  before  "the  task  of  utero-gestation  is 
perfected,"  as  when  it  lives  to  the  full  period;  yet,  in  many  cases 
this  does  not  happen  until  the  period  of  nine  months  have  ex. 
pired.  In  these  instances,  so  far  is  the  neck  of  the  uterus  from 
being  completely  expanded,  that  a  portion  of  it  can  be  distinctly 
felt,  if  it  be  examined  soon  after  the  commencement  of  the  pains. 
Indeed,  the  whole  uterine  bulk  is  oftentimes  found  diminished. 
How  does  the  extreme  sensibility  of  the  os  uteri  perform  its  office 
in  these  cases?  do  they  give  warning  that  the  term  of  gestation  is 
completed  ? 

454.  But  more  powerful  objections  may  be  raised  against  prop, 
tenth,  and  which  will  have  a  direct  application  to  prop,  ninth.  If 
we  understand  Mr.  P.  rightly,  and  we  would  feel  great  reluct- 
ance to  force  his  meaning,  the  following  circumstances  must 
combine,  that  labour  may  take  place;  first  that  an  especial  degree 
of  sensibility  must  reside  in  the  extreme  edge  of  the  os  uteri; 
secondly,  to  make  this  sensibility  available,  the  presenting  part 

*  "A  friend,  a  practitioner  and  lecturer  of  some  eminence,  is  positive  that 
he  has  known  repeated  instances  of  spurious  pains,  in  which  the  cervex  uteri 
has  not  only  been  entirely  obliterated,  but  the  orifice  sufficiently  open  to  ad- 
mit a  couple  of  fingers,  and  yet  labour  has  been  deferred  for  nearly  a  month 
afterwati'ds.  Professor  Hamilton  used  to  mention  cases  in  wliich,  though  the 
cervix  uteri  was  obliterated,  yetreal  labour  had  not  commenced." — Note  by 
Dr.  Lyall  to  minutes  of  the  medical  evidence  given  in  the  Gardner  Peerage  cause, 
p.  23. 

21 


162  CAUSE  OF  LABOUR. 

must  press  upon  it;  and  thirdly,  if  this  be  of  a  minor  kind,  or 
not  reo-ularly  applied,  the  parturient  action  is  less  forcibly  or 
speedily  excited."  p.  39. 

455.  The  first  circumstance  we  have  endeavoured  to  prove, 
does  not  exist  in  the  natural  condition  of  the  part  interested;  and 
if  we  have  been  successful  in  this  attempt,  it  might  look  like  a 
work  of  supererogation  to  offer  objections  to  the  second  and  third, 
as  they  depend,  agreeably  to  Mr.  P.'s  statement,  upon  the  first 
for  their  success  or  influence. 

456.  But  let  us  suppose  this  exalted  sensibility  to  exist;  we 
shall  soon  see  that  it  must  be  called  into  action  if  the  pressure  of 
the  contents  of  the  uterus  be  capable  of  doing  so,  in  a  vast  majo- 
rity of  cases,  long  before  the  <Uask  of  utero-gestation  is  per- 
fected." 

457.  The  history  of  human  gestation  shows,  that  the  con- 
tents of  the  uterus  is  successively  forced  against  the  neck  of  this 
organ  with  more  or  less  force,  immediately  after  the  sixth  month 
is  completed;  and  this,  with  an  urgency  that  is  highly  instru- 
mental in  its  ultimate  expansion — this  alternate  state  of  contrac- 
tion and  relaxation,  is  calculated  to  call  into  play  the  functional 
duty  of  this  part,  rather  perhaps  as  a  congenial  and  appropriate 
stimulus,  than  as  a  mechanical  agent.  But  be  this  as  it  may, 
such  is  the  economy  of  the  uterus  at  the  period  of  gestation  spoken 
of,  that  its  contents  are  regularly  urged  against  its  inferior  portion, 
and  with  such  force  for  at  least  two  months,  as  would  indisputa- 
bly interfere  with  the  comfort  of  the  mouth  of  the  uterus,  did  it 
possess  one-half  of  the  sensibility  so  gratuitously  bestowed  upon 
it  by  Mr.  P. 

458.  Again  we  have  the  "parturient  effort"  regularly  estab- 
lished, where  there  is  no  foetus  within  the  uterus  to  be  urged 
against  the  mouth  of  the  uterus  (as  in  extra-uterine  conceptions,) 
to  rouse  its  sensibility,  that  it  may  give  warning,  that  "  the  task 
of  utero-gestation  is  perfected."  In  these  cases  there  can  be  no 
warning  given  by  the  mouth  of  the  uterus,  as  it  is  not  expanded; 
and  consequently  cannot  avail  itself  of  pressure,  did  it  even  pos- 
sess the  sensibility  contended  for;  since  there  is  not  a  sufficiency 
of  substance  within  the  uterus,  to  be  forced  against  it;  yet  the 
parturient  effort  is  excited, 

459.  It  is  true,  Mr.  P.  is  perfectly  aware  of  this  objection;  but 
is  quite  unwilling  to  admit  its  full  force.  He  says,  that  "extra- 
uterine fcetation,  is  most  commonly  attended  by  pain,  but  these 


CAUSE  OP  LABOUR.  163 

pains  cannot  arise  from  real  expulsive  action  of  the  uterus,  as  that 
organ  contains  nothing  in  fact  to  expel."  We  are  a  little  sur- 
prised at  this  declaration,  as  it  betrays  a  lack  of  candour;  for 
a  practitioner  so  well  read  as  Mr.  P.  cannot  be  ignorant,  that  almost 
every  dissection  of  women  who  have  died  in  consequence  of  an 
extra-uterine  conception,  has  afforded  proof,  that  the  decidua  was 
regularly  formed  within  tlie  uterus;  and  that  in  most  of  these 
cases,  this  substance  has  been  expelled  by  the  regular  action  of 
the  uterus.  We  need  not  cite  authorities  in  proof  of  this;  the 
fact  is  familiar  to  everybody  conversant  with  obstetrics. 

460.  Mr.  P.  farther  observes,  however,  that  "  such  cases  fito 
occasionally  proceed  through  their  whole  series  of  phenomena 
without  any  pain  being  excited."  This  may  be — and  if  they 
do,  they  only  form  exceptions  to  the  rule.  Again  he  observes, 
"  the  pains  at  other  times,  will  commence  in  the  early  stage,  and 
continue  to  be  more  or  less  excited  throughout  the  whole  period 
of  pregnancy."  What  produced  the  pain  in  these  cases?  Most 
probably,  it  may  have  been  an  unusual  quantity  of  the  decidua; 
for  we  are  informed,  that  it  sometimes  abounds. 

461.  Mr.  P.  admits  as  certain,  "that  a  state  of  pain,  which  has 
been  supposed  similar  to  labour  pains,  does  occur  commonly  from 
tJie  eighth  to  the  tenth  month;  it  is  probable,  however,"  he  con- 
tinues, "  that  it  does  not  partake  of  the  nature  of  the  parturient 
paroxysm,  but  consists  of  spasmodic  actions  of  the  surrounding 
parts  unconnected  with  the  uterus.  It  is  also  possible  that  a  trans- 
lation may  be  made  from  those  parts  to  that  organ,  upon  the  prin- 
ciple of  metastasis ;  or  the  child  may  gravitate  during  the  latter 
months  upon  the  cervical  part  of  the  uterus,  which  may  have  un- 
dergone some  similar  preparatory  change  to  what  it  experiences 
in  utero-gestation,  and  thus  produce  certain  actions  of  the  uterus 
by  irritation  of  the  cervix."  p.  41, 

462.  It  will  be  perceived,  that  there  are  three  distinct  posi- 
tions assumed  by  Mr.  P.  in  the  above  quotation;  with  a  view  to 
destroy  the  force  the  cases  of  extra-uterine  conception  offer  to  his 
doctrine;  all  of  which  we  look  upon  as  gratuitous;  we  shall, 
therefore,  try  their  validity,  with  the  arguments  and  facts  which 
observation  has  furnished  us  with. 

463.  Mr.  P.  declares  it  probable,  that  the  pain  the  woman  ex- 
periences between  the  eighth  and  tenth  month  of  gestation,  when 
she  is  carrying  an  extra-uterine  conception,  "is  not  of  the  nature 
of  the  partiu-ient  paroxysm. "     Why  not?  has  it  not  all  its  cha- 


164  CAUSE  OP  LABOUR. 

racters?  is  it  not  alternate?  is  it  not  situated  in  the  uterine  region? 
is  it  not  described  as  a  forcing,  bearing  down  pain?  is  it  not  evident 
that  it  is  owing  to  uterine  contraction,  since,  in  most  instances 
it  is  accompanied  by  a  slight  discharge  of  blood,  and  sometimes 
by  the  discharge  of  a  substance  resembling  the  decidua?  could 
these  phenomena  present  themselves,  if  this  pain  "consisted  of 
spasmodic  actions  of  the  surrounding  parts,  unconnected  with 
the  uterus?" 

464.  We  anticipate  the  answer  of  every  candid  mind  to  these 
questions,  by  believing  it  would  be  in  the  negative.  Mr.  P.  has 
not  urged  a  single  reason  for  the  belief,  that  uterine  contraction 
is  not  the  cause  of  this  pain;  why  he  has  not  done  so,  may  be 
easily  imagined. 

465.  Now  it  seems  to  be  a  matter  universally  ceded,  that  there 
is  a  general  and  pretty  constantly  fixed  period,  at  which  gesta- 
tion ceases,*  and  that,  as  soon  as  this  period  arrives,  the  uterus 
takes  on  the  action  of  expulsion ;  or  in  other  words,  a  period  ar- 
rives very  constantly,  at  which  the  connection  between  mother 
and  child  must  cease — and  this  is,  as  an  average  period,  made  to 
occupy  about  two  hundred  and  seventy-three  to  two  hundred 
and  eighty  days.  It  is  every  way  presumable,  that  everything 
connected  with  pregnancy  in  its  natural  order,  has  a  definite  pe- 
riod of  duration;  as  every  earthly  thing  has  beside,  that  possesses 
life;  consequently  this  principle,  or  condition,  can  be  maintained 
but  for  a  limited  time.  The  decidua  then,  like  everything  else, 
has  a  limited  period  of  vital  energy;  and  that  when  this  time 
arrives,  it  dies,  by  a  law  of  nature;  nor  can  any  art  with  which 
we  are  acquainted,  prolong  its  vital  condition,  one  day  beyond 
this  limit. 

466.  In  the  human  subject  this  takes  place  with  the  decidua, 
at  about  the  end  of  nine  calendar  months;  a  little  sooner,  or  a  lit- 
tle later,  as  its  peculiar  constitution  may  be,  or  as  those  may  be 
with  which  it  is  connected.  If  it  die  within  the  uterus,  it  becomes 
from  that  moment  an  extraneous  body ;  and  sucli  is  the  constitu- 

*  Mr.  P.  admits,  "  It  is  an  established  law  of  the  system,  that  the  connexion 
of  the  child  with  its  mother  should  cease  at,  or  very  soon  after,  the  nmtlimontli 
from  conception;  whenever  this  takes  place,  it  is  probable,  that  tlie  child  be- 
comes an  extraneous  mass,  and  consequently  excites  inordinate  actions  of  the 
parts  around  to  produce  its  removal;  whereas  it  had  previously  constituted  a 
>'ital  part  of  the  system,  and  as  such  had  received  both  support  and  forbearance 
from  it."  p.  42. 


CAUSE  OP  LABOUR.  165 

lion  of  this  organ,  that  it  instantly  sets  about  expelling  the  body, 
be  it  what  it  may,  that  becomes  foreign  to  it  by  losing  its  vitality. 
Thus  it  is  with  the  decidua ;  it  loses  its  life  because  it  cannot  be 
maintained  longer,  agreeably  to  a  law  of  nature;  it  is  then  expel- 
led, by  the  repeated  efibrts  of  the  uterus;  and  these  efforts,  are 
accompanied  by  pain. 

467.  In  dysmenorrhoea,  a  similar  process  is  instituted  to  dis- 
lodge the  membrane  or  coagulum,  produced  within  the  uterus. 
Mr.  P.  might  say  with  equal  propriety,  in  this  case,  that  the  pain 
the  woman  experiences,  "does  not  partake  of  the  parturient 
effort,  because  the  uterus  in  fact  has  nothing  to  expel ;"  yet,  in  both 
instances,  it  extrudes  by  its  action  a  foreign  body. 

468.  If  these  facts,  and  the  reasoning  from  them  be  admitted, 
the  cause  of  pain  at  the  end  of  nine  months,  (more  or  less,)  in 
cases  of  extra-uterine  conceptions,  is  accounted  for;  and  conse- 
quently, the  explanation  of  "  the  nature  and  causes  of  the  partu- 
rient action,"  given  by  Mr.  P.  must  fall  to  the  ground;  since,  it 
may,  nay,  it  is  constantly  produced  in  the  cases  alluded  to,  without 
either  the  condition  of  the  os  uteri  insisted  on  by  him,  or  the  pre- 
sence of  a  child  within  it,  both  of  which  he  considers  as  essential 
to  the  action  in  question. 

46.9.  The  second  position  assumed  by  Mr.  P.  is,  that  the  uterus 
may  be  urged  to  pain,  by  a  translation  of  action  from  "  the  sur- 
rounding parts  unconnected  with  this  organ."  We  confess  our- 
selves entirely  ignorant  of  this  change,  as  we  have  never  witness- 
ed it;  and  are  altogether  at  a  loss  to  account  for  pain  attacking 
the  surrounding  parts,  under  this  particular  form  of  conception  ; 
and  so  uniformly,  at  ihe  same  period  of  gestation,  in  preference 
to  the  uterus  itself,  which  everybody  will  admit,  is  more  impli- 
cated in  the  progress,  and  consequences  of  this  mode  of  gestation, 
(unless  perhaps  it  be  the  very  sac  itself  in  which  the  foetus  is 
concealed,)  than  any  other  portion  of  the  neighbouring  parts. 
Besides,  metastasis  is  the  translation  of  a  morbid  action:  uterine 
contraction  is  normal. 

470.  The  third  position  assumes  an  impossibility ;  namely, 
that  "  the  child  may  gravitate  during  the  latter  months,  upon 
the  cervical  part  of  the  uterus,  which  may  have  undergone  some 
similar  preparatory  change,  to  what  it  experiences  in  utero-ges- 
tation,  and  thus  produce  certain  actions  of  the  uterus,  by  irritation 
of  the  cervix." 

471.  In  cases  of  extra-uterine  conceptions  the  seats  of  de- 


166  CAUSE  OF  LABOUR. 

velopement  are  the  ovarium,  the  tube,  and  the  abdomen;  and 
to  these  has  lately  been  added  a  new  one;  namely,  the  sub- 
stance of  the  uterus  itself.  Now,  if  the  foetus  occupy  either  of 
the  three  first  named  places,  it  is  impossible  that  it  shall  "  gra- 
vitate during  the  latter  months  upon  the  cervical  part  of  the 
uterus;"  unless  it  be  made  to  reach  this  part,  by  some  process 
of  ulceration,  which  it  is  scarcely  worth  while  to  anticipate,  as 
in  this  case,  it  would  not  serve  the  purpose  of  Mr.  P.  The 
whole  arrangement  or  anatomy  of  the  parts,  forbids  the  possibility 
of  a  foetus,  enclosed  in  either  of  the  viscera  just  named,  from 
being  so  precipitated  in  the  pelvic  cavity,  as  to  come  in  contact 
with  the  cervical  part  of  the  uterus. 

472.  Late  pathological  researches  have  discovered,  that  the 
foetus  may  be  included  in  the  proper  substance  of  the  uterus. 
But  even  this  fact  cannot  be  made  subservient  to  the  puiposes  of 
Mr.  P.  He  declares  the  possibility  of  the  fostus  so  to  gravitate, 
as  to  reach  the  cervical  portion  of  the  uterus,  at  the  last  months 
of  utero-gestation;  but,  in  the  newly  discovered  species  of  extra- 
uterine conception,  the  period  of  gestation  has  hitherto  been  con- 
fined to  the  first  few  months,  and  has  proved  fatal  in  every  in- 
stance so  far  known:  consequently,  qannot  be  looked  upon  as  a 
support  to  Mr.  P.'s  conjecture,  (see  pars.  164,  165.) 

473.  It  may  be  farther  urged  against  proposition  tenth,  that  the 
irritation  caused  by  the  presence  of  the  presenting  part,  upon  the 
<' highly  sensitive  os  uteri,"  should  be  in  proportion  to  the  pres- 
sure it  may  exert  upon  it;  now  this  is  contradicted  by  the  expe- 
rience of  everyday.  For  there  are  no  cases  so  uniformly  slow, 
as  those  in  which  the  membranes  have  given  way  early,  and  in 
which  the  presenting  part  "gravitates"  so  decidedly,  "upon  the 
cervical  portion  of  the  uterus."  The  tonic  contraction  of  the 
uterus  almost  immediately  ensues,  after  the  rupture  of  the  mem- 
branes ;  by  which,  the  presenting  part  is  made  to  rest  upon,  and 
mechanically  stretch  the  most  depending  part  of  the  uterus,  (the 
very  situation  contended  for  by  Mr.  P.)  yet  this  condition  may 
remain  from  a  few  hours  to  many  days,  without  having  this  pe- 
riod invaded  by  pain. 

474.  Proposition  eleventh  says  nothing  more,  than  when  the 
uterus  is  entirely  empty,  it  ceases  to  contract ;  this  is  but  as  it 
should  be ;  or  the  poor  female,  who  has  had  her  uterus  once 
forced  to  contraction,  would  never  have  it  to  cease,  did  not  a 
state  of  vacuity  prove  a  guarantee  against  them.     It  is,  there- 


CAUSE  OF  LABOUR.  167 

fore,  every  way  presumable,  that  in  the  case  of  a  rupture  of  the 
uterus,  when  the  fcjctus  and  sccundines  have  escaped  from  it,  that 
this  oi-gan  would  cease  to  contract,  as  no  motive  now  remained  for 
this  function;  to  say  nothing  of  the  extreme  state  of  exhaustion 
this  accident  uniformly  produces,  which  of  itself  is  capable  of  ar- 
resting uterine  contraction. 

475.  Mr.  P.  says  "the  contractions  of  the  os  uteri  may  be  ar- 
tificially excited  by  an  irritation  applied  to  the  orifice,  affording  a 
proof  that  the  cause  presumed,  is  adequate  to  produce  the  effect 
attributed  to  it,"  p.  39.  Admitted;  but  what  does  it  prove  in 
favour  of  Mr.  P.'s  hypothesis?  nothing;  especially,  as  Mr.  P.  will 
not  declare  it  to  be  a  natural  state  of  function.  Irritating  the 
fauces  will  produce  vomiting,  and  a  dose  of  jalap  will  purge:  but 
will  anybody  acknowledge  either  to  be  essential  to  the  emptying 
of  the  stomach  and  bowels  under  the  exercise  of  their  natural  or 
normal  actions? 

476.  Mr.  P.  with  a  view  of  strengthening  his  conjecture, 
quotes  a  letter  from  his  father.  Dr.  Power,  of  Litchfield.  He  com- 
mences his  letter  by  saying,  "that  the  parturient  contraction 
does  not  happen  in  consequence  of  distention  of  the  uterus  after 
nine  months  pregnancy,  but  from  some  stimulus  applied  to  the  os 
uteri,  may  be  inferred  from  the  following  case." 

477.  "  A  woman,  forty  years  of  age,  the  mother  of  many  chil- 
dren, cqnsidered  herself  at  the  full  period  of  utero-gestation,  and 
experienced  at  that  period  a  slight  pain  or  two,  after  which  she 
became  free  from  any  further  efibrt  for  nearly  three  months;  her 
situation  exciting  alarm,  several  medical  gentlemen  saw  her,  and 
declared,  after  examination  per  vaginam,  that  she  was  not  with 
child,  as  they  could  feel  no  weight  upon  the  os  uteri,  or  variation 
of  it,  from  what  is  found  in  the  unimpregnated  state.  I  saw  her, 
and  in  a  common  examination  as  she  lay  upon  the  bed,  found 
matters  apparently  as  had  been  represented ;  observing,  however, 
the  abdomen  very  large  and  pendulous,  hanging  down  when  in 
an  erect  posture  almost  to  the  knees.  A  friend  of  hers,  a  physi- 
cian of  great  eminence,  who  was  present,  was  requested  to  stand 
above  her  on  a  chair,  and  to  elevate  as  he  stood,  the  pendulous 
belly  with  the  assistance  of  a  napkin  ;  an  examination  was  made 
under  these  circumstances  per  vaginam,  and  I  could  feel  now  dis- 
tinctly the  head  of  the  child.  A  bandage  was  contrived  with 
straps  to  her  stays,  by  which  the  child  was  removed  from  its 
situation  over  the  pubes;  and  in  four  or  five  days  labour-pains 


168  CAUSE  OF  LABOUR. 

came  on,  and  she  was  delivered  of  an  amazing  large  but  still-born 
child."  p.  40. 

478.  To  this  case  it  will  be  only  necessary  to  observe,  that 
there  is  not  the  slightest  evidence  of  the  agency  of  the  present- 
ing part,  in  producing  labour.  For  it  is  acknowledged  that  the 
patient  was  the  mother  of  "many  children;"  and  consequently 
liable  from  this  cause  to  the  anterior  obliquity  of  the  uterus; 
for  it  is  by  no  means  probable  that  this  was  the  first  instance  of 
deviation;  especially  as  it  was  so  extreme  as  to  reach  nearly  to 
the  knees  when  the  woman  was  standing.  If  it  existed  in  her 
previous  pregnancies,  how  did  labour  commence  in  them,  if  the 
aid  given  by  Dr.  Power  was  essential  to  this  process,  since  it  was 
not  resorted  to  upon  the  former  occasions? 

479.  Besides,  Dr.  P.  acknowledges  that  four  or  five  days 
elapsed  before  labour  took  place;  if  this  be  so,  w^hat  evidence  is 
there  that  the  head  pressing  against  the  os  uteri  was  the  cause  of 
it?  none  whatever.  It  is  much  more  probable  if  anything 
had  an  influence  upon  uterine  contraction,  that  it  was  the  change 
of  position  and  the  bandages ;  as  it  is  well  known  that  external 
friction  over  the  body  and  fundus  will  produce  contraction,  even 
when  the  uterus  is  in  a  state  of  inertia.  Again,  we  have  seen 
many  cases  of  anterior  obliquity,  in  neither  of  which  was  it  ne- 
cessary to  have  recourse  to  the  means  employed  by  Dr.  P.  to 
provoke  labour — it  always  came  on  spontaneously  at  the  appoint- 
ed time. 


169 


CHAPTER  XII. 


OP  LABOUR. 


480.  Whatever  uncertainty  may  exist  as  to  the  efficient 
cause  of  labour,  we  are  taught  by  long  experience,  that  about  the 
fortieth  week  of  gestation  there  is  for  the  most  part,  a  painful 
effiart  made  by  the  uterus  to  expel  its  contents;  and  this  effort  is 
called  labour.  This  event  rarely  takes  place  so  suddenly,  or  so 
silently,  as  not  to  present  a  very  regular  series  of  phenomena, 
which,  from  their  universality,  must  be  considered  as  constituting 
a  part  of  this  process  ;  and  some  of  them  perhaps  must  be  looked 
upon  as  essential  to  its  well  performance.  The  appearances  to 
which  I  allude  may  be  divided,  1st,  into  those  which  affect  the 
system  at  large ;  as  rigors,  and  a  number  of  what  are  denominated 
nervous  symptoms;  2d,  into  those  which  affect  certain  portions 
of  the  system  independently  of  the  uterine;  as  frequent  inclination 
to  make  water,  or  a  suppression  of  it,  and  tenesmus;  3d,  into 
those  which  affect  the  uterus  in  particular;  as  the  subsiding  of  the 
uterine  globe;  the  secretion  of  mucus ;  the  dilatation  of  the  mouth 
of  the  uterus,  and  its  alternate  contractions. 

Sect.  I. — 1.  Of  Rigors,  4'C. 

481.  It  is  a  very  usual  thing,  especially  with  nervous  women, 
to  be  seized  with  rigors  of  more  or  less  severity,  in  the  very  com- 
mencement of  the  silent  preparations  for,  or  during  the  more  evi- 
dent progress  of  the  labour.  These  shiverings,  or  rather,  trem- 
blings, are  never  attended  with  a  reaction  of  the  system ;  and 
therefore,  must  not  be  considered  as  ushering  in  fever.  These 
rigors  would  seem  to  be  connected  in  somemanner  with  the  dila- 
tation of  the  OS  uteri;  and  occur  most  certainly,  where  this  is  ra- 
pidly performed.  Nor  do  I  at  this  moment  recollect  an  instance  of 
rigor  taking  place,  where  the  os  uteri  was  not  more  or  less  dilated. 
One  of  the  most  remarkable  examples  of  this  kind,  I  recollect  to 
have  witnessed,  was  with  a  lady,  who  awoke  with  a  smart  rigor 
from  a  sleep,  and  who  every  moment  expected  her  labour  to  com- 
mence; the  nurse  became  alarmed,  and  I  was  immediately  sen^ 
for — when  I  arrived,  I  found  her  still  trembling  very  severely,  but 
had  not  experienced  any  symptom  of  labour — she  assured  me, 

22 


170  FREQUENT  INCLINATION  TO  MAKE  WATER,  &C. 

that  nothing  was  the  matter  with  her,  except,  what  I  was  wit- 
nessing; namely,  an  agitation  of  the  whole  body,  which  she  could 
not,  by  any  effort,  control.  It  was  an  extremely  cold  night, 
and  I  had  approached  the  fire;  but  I  had  not  been  there  five  mi- 
nutes before  my  patient  exclaimed,  she  believed  her  labour  was 
coming  on;  and  this  really  was  the  case,  and  so  rapidly,  as  not  to 
give  me  time  to  place  her  in  a  proper  situation  for  delivery ;  she 
was  delivered  in  less  than  five  minutes  from  the  time  she  first 
called  my  attention  to  her. 

482.  When  these  tremblings  take  place  later  in  the  process,  I 
have  always  felt  assured  the  mouth  of  the  uterus  was  dilating  or 
dilated.  They  sometimes  occur  immediately  after  labour.  And, 
so  far  as  I  have  witnessed,  they  have  never  been  attended  by  the 
sensation  of  cold.  Nor  have  I  ever  known  them  do  the  slightest 
injury:  though  the  patient  and  her  friends  are  oftentimes  so  much 
alarmed,  as  to  commit  an  error,  by  giving  stimulating  or  heating 
drinks;  &c. — in  a  word  they  require  no  attention. 

483.  Besides  the  rigor  I  have  just  mentioned,  we  sometimes  see 
a  number  of  nervous,  or  hysterical  symptoms,  attend  the  progress 
of  labour;  especially,  with  the  first  child,  if  the  process  be  rather 
slow — such  as  a  disposition  to  cry,  a  sense  of  suffocation  or  choak- 
ing,  palpitation  of  the  heart,  &c. ;  all  of  which,  however,  are  al- 
most sure  to  disappear  so.  soon  as  the  labour  becomes  active,  and 
the  pains  succeed  each  other  quickly.  Should  they  be  violent,  a 
little  of  the  tincture  of  assafoctida,  or  Hoffman's  anodyne  liquor, 
may  be  advantageously  administered.  Under  such  circumstances, 
we  should  give  the  patient  every  reasonable  assurance  of  a  hap- 
py termination  of  her  sufferings;  and  that  there  is  nothing  un- 
common in  her  situation. 

Sect.  II. — 2.  Frequent  inclination  to  make   Water,  Tenes- 
mus, Sf-c. 

484.  The  uterus  even  in  the  commencement  of  labour,  if  the 
fundus  and  body  of  this  organ  act  healthily,  is  very  often  found 
so  low  in  the  pelvis,  as  to  press  upon  some  portion  of  the  blad- 
der :  but  especially,  upon  the  neck ;  this  pressure  excites  a  fre- 
quent inclination  to  make  water;  in  obeying  which,  the  woman 
always  suffers  more  or  less  inconvenience.  Under  such  circum- 
stances, the  urine  is  very  frequently  driven  from  the  bladder  in 
small  quantities,  by  every  contraction  of  the  uterus ;  this  often 
leads  the  patient  and  her  friends  to  believe  that  the  liquor  amnii 


FREQUENT  INCLINATION  TO  MAKE  WATER,  &C.  171 

is  escaping.  This  I  think,  more  frequently  happens  where  the 
OS  uteri  opens  reluctantly;  and  where  the  pains  are  pretty  fre- 
quent and  severe — it  needs  no  application,  unless  the  inclination 
cannot  be  obeyed,  and  it  amount  to  retention;  in  such  case,  the 
catheter  must  be  introduced;  nor  should  this  condition  be  sufler- 
ed  to  remain  too  long  without  being  relieved  by  this  instrument. 
This  retention,  so  far  as  I  have  witnessed,  never  takes  place  but 
in  protracted  labours,  and  especially  in  such  as  may  require  arti- 
ficial means  for  their  relief.  It  should  ever  be  a  rule  to  inquire 
frequently  into  the  state  of  the  bladder  in  all  cases  of  tedious 
labour;  and,  should  the  patient  have  been  several  hours  without 
passing  urine,  the  catheter  should  be  employed;  and  particularly, 
if  there  be  no  prospect  that  the  labour  will  terminate  speedily. 
Much  present  inconvenience,  and  sometimes  lasting  mischief, 
have  arisen  from  the  neglect  of  this  precaution — I  have  seen  this 
disposition  continue  for  days  after  delivery,  and  relieved  only  by 
the  occasional  use  of  the  catheter;  I  have  known  an  opening  take 
place  between  the  urethra  and  the  vagina  by  the  part  sloughing; 
and  this  in  consequence  of  long  pressure ;  and  witnessed  an  in- 
continency  of  urine  from  the  same  cause. 

485.  In  a  case  of  the  latter  kind,  I  was  once  consulted  by  my 
friend  Dr.  William  Harris,  in  which  entire  relief  was  procured 
by  the  use  of  the  tincture  of  cantharides.  In  this  patient  the  sti- 
licidium  of  urine  was  so  constant,  as  to  lead  to  the  suspicion  there 
was  an  artificial  opening  from  the  urethra;  but  a  careful  exami- 
nation could  detect  no  such  state — I  think  this  lady  has  had  a 
child  since  that  period  without  this  accident  being  renew^ed ;  but 
of  this  I  am  not  certain. 

486.  It  is  not  unfrequent,  at  the  commencement  of  labour,  for 
the  bowels  to  be  several  times  moved  in  pretty  quick  succession, 
accompanied  with  a  strong  effort  or  tenesmus;  or  this  inclination 
may  take  place  after  the  labour  is  advanced,  from  the  mechanical 
pressure  the  rectum  suffers  from  the  loaded  uterus  completely 
occupying  the  vagina.  In  the  first  case,  should  there  appear  to 
be  sufficient  time  to  permit  its  operation,  a  full  dose  of  castor  oil 
will  be  sure  to  remove  it — should  there  not  be  time,  five-and- 
tvventy  drops  of  laudanum  will  speedily  quiet  this  inclination.  In 
the  last  case  we  can  offer  no  relief,  unless  the  rectum  be  impacted 
with  hardened  faeces,  which  do  not  escape  from  it,  even  by  the 
repeated  pressure  of  the  child's  heud — when  thus  situated,  an 
emollient  injection  will  almost  always  procure  relief. 


172  OF  THE  SUBSIDING  OP  THE  ABDOMINAL  TUMOUR. 

Sect.  III. — 3.  Sjfections  of  the  Uterine  System  in  particular. 

487.  These  last  are  of  much  more  importance  than  those  we 
have  just  been  considering;  and  most  of  them  may  be  looked 
upon  as  always  accompanying  every  healthy  labour,  and  may 
be  divided  into 

a.  The  subsiding  of  the  abdominal  tumour. 

b.  The  secretion  of  mucus. 

c.  The  dilatation  of  the  os  uteri. 

d.  The  alternate  contractions  of  the  uterus.  • 

a.— Of  the  Subsiding  of  the  Mdominal  Tumour. 

488.  When  the  uterus  and  pelvis  are  in  a  healthy  condition, 
the  fundus,  at  the  last  period  of  utero-gestation,  is  found  little  or 
no  higher  than  at  the  eighth  month  ;  the  reasons  for  this  are,  first, 
the  constant  tendency  which  the  body  and  fundus  have  to  contract 
after  the  seventh  month,  forces  the  uterine'  contents  lower  into 
the  pelvis ;  and  second,  the  effect  of  these  contractions  upon  the 
neck  of  this  organ,  causes  it  to  unfold,  and  thus  furnishes  additional 
room  for  the  increasing  fatus.  In  consequence  of  the  develope- 
ment  of  the  neck,  the  uterine  contents  must  necessarily  sink 
lower  into  the  pelvis  even  without  the  agency  of  the  contrac- 
tions just  spoken  of;  but  especially,  when  these  take  place  in  a 
healthy  and  natural  manner.  The  existence  of  these  contractions, 
can  be  ascertained,  by  the  introduction  of  the  finger  into  the  os 
uteri,  and  placing  its  extremity  gently  against  the  membranes; 
when  thus  situated,  they  will  be  found  to  be  alternately  tense  and 
relaxed* — the  effect  of  these  contractions  will  be  the  obliteration 
of  the  neck  of  the  uterus,  and  eventually  producing  labour  itself. 

489.  The  sinking  of  the  uterus  into  the  pelvist  has  been  just- 
ly considered  a  favourable  circumstance ;  as  it  would  seem  to  de- 
clare two  important  facts:  1st.  A  healthy  condition  of  the  uterus 
itself;  and  2nd.  A  healthy  conformation  of  the  pelvis, 

b.  —  The  secretion  of  Mucus. 

490.  This  important  discharge  almost  always  takes  place,  even 
before  other  symptoms  declare  labour  to  be  at  hand.  Its  forma- 
tion is  the  result  of  one  of  the  numerous  sympathies,  to  which  the 

*  Baudclocque. 

t  The  old  women  cull  this  falling. 


THE  SECRETION  OP  MUCUS.  173 

uterine  system  lays  claim.  It  is  always  a  welcome  harbinger  to 
the  accoucheur,  as  it  almost  always  foretells  the  condition  of  the 
parts,  or  ensures  a  favourable  disposition  in  them  to  relax;  and 
this  disposition  is,  ceteris  paribus,  almost  in  proportion  to  the 
quantity  secreted.  When  it  does  not  appear  in  the  beginning 
of  labour,  even  where  the  pains  are  frequent  and  severe,  we 
rarely  find  upon  examination,  that  the  labour  has  progressed 
much,  or  that  the  os  uteri  is  well  dilated.  But  if  a  quantity 
be  quickly  secreted,  even  very  soon  after  we  have  made  an 
examination,  it  will  be  found,  that  the  orifice  of  the  uterus  has 
suddenly  undergone  a  change,  by  being  either  perhaps  well  dila- 
ted, or  easily  dilatable — hence,  we  infer,  it  is  in  some  way  or 
other  connected  with,  or  instrumental  to,  this  process. 

491.  This  discharge  is  frequently  tinged  with  blood;  this  co- 
lour is  derived  from  the  rupture  of  some  small  blood-vessels  of 
the  chorion,  or  perhaps  of  the  placenta.  When  not  tinged  with 
blood,  it  much  resembles  the  white  of  an  egg.  Dr.  Denman 
calls  it  an  increased  secretion  of  the  fluid  natural  of  the  parts; 
but  to  this  it  does  not  appear  to  bear  the  least  resemblance — 
and  if  it  be  even  furnished  by  the  same  vessels,  it  must  be  by  an 
altered  action  of  them. 

492.  The  formation  of  this  fluid  answers  two  important  ends; 
1st.  It  lubricates  the  vagina,  which  permits  the  foetus  to  pass 
more  easily ;  2d.  It  acts  as  topical  depletion  from  the  neck  of  the 
uterus,  vagina,  and  peringeum;  and  thus  facilitates  their  relaxa- 
tion. This  last  circumstance  I  consider  to  be  the  chief  use  of  this 
discharge;  for  were  it  confined  to  the  mere  lubrication  of  the  pas- 
sage, its  utility  would  be  much  more  limited  than  it  is  found  to 
be;  for  this  end  could  be  answered  very  well  by  artificial  means; 
but  these  it  is  well  known  are  not  adequate. 

493.  The  writers  on  midwifery  have  too  much  limited  the 
usefulness  of  this  discharge;  they  look  upon  it  as  a  mere  lubricant; 
and  they  carefully  caution  against  too  frequent  touching,  lest, 
say  they,  it  remove  this  substance  from  the  vagina,  and  thus 
give  rise  to  more  friction  between  the  child's  head,  and  the  soft 
parts  of  the  mother:  now,  were  this  the  only  evil  to  be  apprehend- 
ed by  incautious  or  unnecessary  touching,  it  could  be  easily  re- 
medied by  any  mild  unctuous  substance;  but,  as  I  have  just  ob- 
served, it  is  well  known,  though  not  acknowledged,  that  this  sub- 
stitute by  no  means  answers  the  purpose  for  which  I  believe  this 
discharge  was  instituted. 


174  OF  THE  DILATATION  OF  THE  OS  UTERI. 

494.  By  frequent  and  incautious  touching,  the  glands  furnish- 
ing this  fluid  are  over-stimulated,  nay,  sometimes  become  in- 
flamed. In  this  case,  the  secretion  ceases,  and  the  parts  become 
tender  and  swoln;  especially,  the  mouth  of  the  uterus,  should  it 
not  be  fully  dilated;  the  pains  are  less  frequent,  and  less  pro- 
trusive; the  woman  is  restless,  and  enjoys  no  calm  in  the  intervals 
of  the  pains;  fever  is  excited;  headache,  thirst,  and  a  hot  skin 
follow;  in  a  word,  a  new  condition  of  the  system  arises,  and  al- 
most suspends  the  business  of  labour.  It  would  be  in  vain,  under 
such  circumstances,  to  offer  a  substitute  for  the  absent  mucus,  by 
presenting  to  the  parts  any  unctuous,  or  mucilaginous  substance 
whatever — it  can  only  be  recalled  by  rest,  and  free  blood-letting. 
To  the  latter,  we  must  have  immediate  recourse,  if  we  wish  to 
subdue  the  unnecessarily  provoked  inflammation;  and  to  restore 
the  uterus  to  the  re-enjoyment  of  its  suspended  powers — in  many 
cases  like  those  just  mentioned,  I  have  seen  this  remedy  act  with 
the  certainty,  and  promptitude  of  a  charm. 

495.  The  disturbance  excited  throughout  the  system  when  the 
vaginal  surface  becomes  inflamed,  distinctly  shows  the  important 
role  this  mucous  secretion  performs  in  the  economy  of  labour; 
it  demonstrates  that  it  is  instituted  for  a  much  higher  purpose 
than  merely  to  lubricate  the  parts:  it  shows  clearly,  that  its  form- 
ation is  in  some  way  or  other  connected  with  the  dilatation  of 
the  OS  uteri,  and  the  relaxation  of  the  perinaeum — let  us  beware 
then  how  we  interrupt  its  formation,  by  rude  and  uncalled  for 
handling. 

c. — Of  the  Dilatation  of  the  Os  Uteri. 

496.  All  writers  upon  midwifery,  make  this  important  ope- 
ration the  efiect  of  mechanical  impulse,  though  many  of  them, 
at  the  same  time,  are  forced  to  acknowledge,  they  have  seen  it 
dilate,  where  neither  the  distended  membranes,  nor  any  portion 
of  the  child  has  entered  its  circle,  to  efiect  its  opening  by  a 
wedge-like  action.  That  the  waters  distending  the  membranes 
and  the  child  itself,  when  powerfully  impelled  by  uterine  con- 
traction, may  occasionally  have  an  influence  on  this  operation,  I 
am  not  disposed  to  deny;  but  if  this  take  place,  it  does  not  open 
this  part  either  so  kindly,  or  so  effectually,  as  when  this  is 
achieved  by  the  powers  destined  for  this  purpose.  Before  I  oflTer 
a  different  explanation  of  this  phenomenon,  it  will  be  necessary 


THE  CONTRACTION  OP  LONOITUDINAL  FIBRES.  175 

to  consider  the  different  Idnd  of  contractions  performed  by  the 
uterus;  they  arc 

497.  a.  The  contraction  of  the  longitudinal  fibres  of  this  organ. 

b.  The  contraction  of  the  circular  fibres. 

c.  The  simple  contraction. 

d.  The  compound  contraction. 

e.  The  tonic  contraction  and  its  effects. 

f.  The  spasmodic,  or  alternate  contraction,  and  its  effects. 

«. —  The  Contraction  of  the  Longitudinal  Fibres. 

498.  By  the  longitudinal  fibres  of  the  uterus,  I  wish  to  signify 
those  fibres  upon  the  contraction  of  which  the  uterus  is  shortened 
from  fundus  to  mouth,  and  which  will  be  in  proportion  to  the 
effort.  The  effect  of  this  contraction  is,  to  make  the  contents  of 
the  uterus  approach  its  mouth;  as  this,  from  its  organization, 
must  necessarily  be  the  least  resisting  part — this  tendency  will 
constantly  be  in  proportion  to  the  diminution  of  resistance,*  and 
the  force  with  whidi  these  fibres  act.  It  will  be  perceived,  that 
if  the  uterus  be  diminished  in  length,  it  will,  necessarily,  be  in- 
creased in  breadth,  unless  opposed  by  the  circular  fibres;  or,  in 
other  words,  the  circular  fibres  would  be  put  upon  the  stretch, 
until  the  diminished  length  be  compensated,  did  they  not  resist 
this  violence,  by  being  stimulated  to  contraction,  by  the  uterus 
becoming  shorter  from  fundus  to  mouth  by  the  contraction  of  the 
longitudinal  fibres,  asd  which  necessarily  tend  to  distend  the 
uterus  in  its  transverse  direction.  But  being  thus  excited  to  ac- 
tion, the  two  sets  of  fibres  urge  the  contents  of  the  uterus  towards 
the  least  resisting  part  of  itself,  namely,  the  mouth;  by  which 
means  the  membranes  become  distended,  and  lengthened  in  the 
direction  of  the  longitudinal  axis  of  this  viscus,  nearly  as  much 
as  this  set  of  fibres  shorten  themselves.  The  action  of  the  lon- 
gitudinal fibres  is  at  right  angles,  with  the  circular;  and  has  a 

*  The  duration  of  labour  will  therefore  almost  invariably  depend  upon  the  re- 
sistance of  the  circular  fibres  of  the  mouth  of  the  uterus,  (all  things  being  equal.) 
It  is  evident  to  every  experienced  accouclieur,  that  the  circular  fibres  constitu- 
ting the  moutli  of  the  uterus,  have  difi'erent  degrees  of  disposition  to  relax,  when 
acted  upon  by  tlie  contracting  body  and  fundus;  in  some  instances,  the  long- 
continued  efforts  of  the  body  and  fundus  are  required  ere  they  yield;  while  in 
othei-s,  contraction  scarcely  takes  place  before  they  give  way,  and  permit  the 
presenting  part  to  j^ass  freely ;  nay,  sometimes  rapidly. 


176  OF  THE  SIMPLE  CONTRACTION. 

tendency  to  oppose,  or  overcome  the  disposition  of  the  circular 
fibres  to  narrow  the  uterus  in  its  transverse  direction. 

b. —  The  Contraction  of  the  Circular  Fibres. 

499.  By  the  circular  fibres  I  mean  those  which  are  arranged 
transversely  from  the  mouth  to  the  fundus,  and  which,  by  con- 
tracting, diminish  the  capacity  of  the  uterus  in  the  direction  of  the 
transverse  diameter;  and  should  they  act  alone,  and  the  os  uteri 
be  closed,  they  would  necessarily  stretch  the  uterus  in  the  direc- 
tion of  its  vertical,  or  longitudinal  diameter.  These  fibres,  as  we 
have  said,  may  be  considered  as  running  round  the  uterus,  from 
the  fundus  to  the  termination  of  the  neck;  they  have,  as  I  shall 
attempt  to  prove  presently,  but  an  indirect  agency  in  furthering 
the  expulsion  of  the  uterine  contents;  the  action  of  the  circular 
fibres,  especially  at  the  neck  of  the  uterus,  is  almost  in  direct  op- 
position to  the  longitudinal,  and  serves  rather  to  retain  than  to 
expel  the  contents  of  the  uterus.  It  is  by  the  successful  and  uni- 
form contraction  of  these  fibres,  and  especially  those  of  the  neck, 
that  the  woman  is  enabled  to  carry  the  produce  of  conception  to 
the  full  period  of  utero-gestation.  They  may  act  independently, 
of  the  longitudinal  fibres;  or  they  may  act  with  greater  force,  as 
I  shall  have  occasion  to  remark  by  and  by. 

c. — Of  the  Simple  Contraction. 

500.  When  either  the  longitudinal  or  circular  fibres  act  alone, 
« the  simple  contraction"  takes  place.  It  may  be  asked  what  evi- 
dence have  we  that  one  set  of  fibres  can  act  independently  of  the 
other?  I  answer,  of  this  we  have  abundant  proof  in  the  contrac- 
tions which  take  place  towards  the  latter  period  of  gestation;  and 
of  which  we  are  made  sensible,  by  passing  the  finger,  as  already 
mentioned,  (488,)  within  the  os  tincai,  and  placing  its  extremity 
against  the  membranes — a  tense  and  relaxed  condition  of  the 
membranes  is  perceived:  this  is  owing  to  the  longitudinal  fibres 
acting  alone,  for  did  the  circular  act  at  the  same  time,  it  would 
be  felt  by  the  finger,  by  the  edges  of  the  os  uteri  stifiening  or  be- 
coming rigid;  but  this  is  not  the  case.  On  the  other  hand,  we 
prove  that  the  circular  fibres  may  contract  firmly,  and  for  a  long 
time,  without  the  slightest  co-operation  of  the  longitudinal  fibres, 
by  the  well  known  circumstance  that  when  the  waters  have  been 
discharged  for  some  time,  the  uterus  is  found  to  embrace  the  body 


OP  THE  TONIC  CONTRACTION  AND  ITS  EFFECTS.  177 

of  the  child  firmly ;  in  this  case  it  is  evident  that  the  circular 
fibres  contract  alone,  as  there  is  no  effort  to  expel  the  child,  as 
would  be  the  case,  did  the  longitudinal  fibres  exert  an  influence 
at  the  same  time. 

d. — Of  the  Comj}ound  Contraction. 

501.  This  contraction  is  the  effect  of  both  sets  of  fibres  acting 
simultaneously;  this  is  proved  by  the  mouth  of  the  uterus  at- 
tempting to  close  itself  during  the  period  of  action,  and  by  the 
head,  or  presenting  part,  evidently  sinking  lower,  (though  per- 
haps to  rise  again  immediately,)  in  the  pelvis.  Now,  these  two 
circumstances  could  not  happen  at  one  and  the  same  time,  did 
not  both  sets  of  fibres  contract  together — it  is  this  compound  ac- 
tion, which  attends  the  commencement  of  all  healthy  or  regular 
labours. 

e. — Of  the  Tonic  Contraction  and  its  Effects. 

502.  The  tonic  contraction,  or  that  contraction  which  tends  to 
diminish  the  uterus  in  all  directions,  (250)  cannot  be  called  into 
action  to  any  extent  until  the  uterus  is  either  in  part,  or  altoge- 
ther deprived  of  its  contents;*  but  if  this  happen  even  in  a  small 
degree,  the  whole  of  the  fibres  of  which  the  uterus  is  composed, 
begin  to  shorten,  or  fold  themselves  up,  and  thus  make  the  uterus 
accommodate  itself  to  the  quantity  and  almost  the  shape  of  its  con- 
tents. In  consequence  of  this,  the  direction,  and  perhaps,  the 
size  of  the  blood-vessels  of  this  organ  are  changed;  and  though 
in  no  very  sensible  degree  at  first,  or  when  its  contents  are  but 
little  diminished,  yet  it  will  be  found,  that  the  changes  will  bear 
an  exact  proportion  to  the  evacuation  from  the  uterus.  It  is  this 
contraction  which  preserves  the  woman  from  fatal  haemorrhage, 
when  the  placenta  is  either  partially,  or  altogether  detached;  it 
serves  also  the  important  purpose  of  keeping  the  uterus  in  con- 
stant contact  with  its  contents,  and  enables  its  fibres  to  act  with 
more  efficiency  upon  the  body,  to  be  expelled;  it  is  also  this  con- 
traction which  opposes  the  re-distention  of  the  uterus;  and  so  ob- 

*  Whatever  will  weaken  the  force  of  the  uterus,  or  diminish  the  quantity  of 
jts  contents,  will  permit,  in  that  proportion,  the  tonic  contraction  of  the  uterus 
to  take  place,  if  this  organ  be  in  a  healthy  condition;  even  a  less  quantity  of 
blood  in  tlie  parietes,  or  a  very  partial  dilatation  of  the  os  uteri,  or  the  escape  of 
a  very  small  quantity  of  the  liquor  amnii,  will  do  the  same. 
23 


178  SPASMODIC  OR  ALTERNATE  CONTRACTION,  &C. 

stinately  does  it  do  this  sometimes,  that  turning  is  rendered  im- 
practicable. 

f, — Of  the  Sjjasmodic  or  Alternate  Contraction,  and  its  Effects. 

503.  This  contraction  is  often  called  the  spasmodic  contrac- 
tion; but  I  prefer,  as  I  have  already  observed,  (254)  the  term 
alternate  or  periodical  contraction;  for  it  is  not  necessarily  ac- 
companied with  pain. 

504.  The  cause  of  these  contractions,  like  the  contractions  of 
every  other  muscle,  must  be  a  stimulus  of  some  kind  or  other;  I 
have  already  declared,  (161)  my  ignorance,  of  the  nature  of  the 
stimulus  that  excites  the  uterus  to  contraction,  at  the  end  of  nine 
months;  though  we  are  very  often  enabled  to  detect  it,  before  that 
period;  for  it  is  always  found,  that  whatever  can  stimulate  this 
organ  to  a  certain  degree,  is  capable  of  provoking  its  action:  and  if 
not  interrupted  by  proper  counter-agents,  it  goes  on  until  the  con- 
tents of  the  uterus  are  expelled.  So  much  for  the  causes  which  may 
excite  the  uterus  to  action^  but  what  is  it  that  gives  these  contrac- 
tions their  alternate  or  periodical  form?  So  far  as  I  know,  a  solu- 
tion to  this  question  has  never  been  given;  indeed,  I  am  not  cer- 
tain, it  has  ever  been  asked ;  therefore  if  I  fail  to  be  satisfactory  in 
the  one  about  to  be  offered,  it  must  be  remembered  I  only  hazard 
a  conjecture;  and  it  will  but  share  the  fate  of  thousands  upon 
every  subject,  from  the  time  of  Hippocrates  to  the  present  mo- 
ment. 

505.  In  order  that  a  muscle  may  renew  its  contraction,  it  must 
be  elongated  by  some  antagonizing  power,  after  it  has  become  re- 
laxed; in  almost  every  part  of  the  body  this  power  is  at  once  dis- 
coverable; but,  where,  and  in  what  resides,  that  which  enables 
the  uterus  to  repeat  its  efforts?  I  am  of  opinion  this  power  de- 
pends upon  its  own  structure,  and  economy — I  shall  now  attempt 
to  prove  this.  The  uterus,  by  impregnation,  becomes  of  course 
distended,  in  proportion  as  that  process  advances — it  is,  therefore, 
elongated,  or  its  fibres  put,  to  a  certain  extent,  upon  the  stretch, 
and  are  thus  enabled  to  contract,  so  soon  as  the  appropriate  sti- 
mulus be  applied.  What  is  the  efiect  of  this  contraction?  An 
approximation  of  the  uterine  fibres;  a  compression  of  all  its  blood- 
vessels, with  the  immediate  discharge  of  a  large  portion  of  blood 
from  them  into  the  general  system:  in  consequence  of  this,  the 
uterus  becomes  paler  and  the  vessels  empty,  or  nearly  so.  The 
blood  escapes  by  means  of  this  contraction  quaquaversum;  and 


SPASMODIC  OR  ALTERNATE  CONTRACTION,  &C.  179 

to  facilitate  its  departure,  the  anastomoses  between  the  arteries 
and  veins,  are  unusually  frequent;  and  the  latter  vessels  are  not 
furnished  with  valves. 

506.  What  is  the  effect  of  the  subsequent  relaxation?  The 
fibres  of  the  uterus  become  longer,  straighter,  and  more  easily- 
distensible;  the  large  vessels  and  sinuses  are  less  compressed, 
and  consequently  w^ill  now  permit  the  natural  resiliency  of  their 
coats  to  act — while  the  influent  blood  will  suddenly  fill  them,  and 
thus  restore  the  equilibrium  which  the  previous  contraction  had 
destroyed — now,  this  rapid  influx,  will  not  only  distend  the  empty 
vessels,  but  will  also  prove  a  powerful  stimulus  to  the  uterine 
fibres;  and  thus  urge  them  to  renew  their  contraction;  and  this 
will  be  repeated  from  time  to  time,  until  there  be  no  farther  ne- 
cessity for  its  continuance.  This  plethoric  state  of  the  uterus,  if 
we  may  so  term  it,  is  proved  by  the  heightened  colour  of  its 
parietes. 

507.  I  presume,  when  this  contraction  is  best  performed,  it  is 
chiefly  by  the  exertion  of  the  longitudinal  fibres. 

508.  This  opinion  is  founded  upon  the  relative  strength  of  the 
two  sets  of  fibres.  I  believe  that  the  longitudinal  fibres,  or  those 
which  by  contracting  shorten  the  uterus,  are  the  stronger  of  the 
two ;  and  for  the  following  reasons:  1st.  Because,  if  they  were 
of  equal  strength,  delivery  could  not  take  place ;  as  the  circular 
fibres  by  their  contractions,  would  rather  embrace  and  retain 
the  child,  than  advance  it;  since,  they  tend  to  diminish  the 
transverse  diameter  of  the  uterus;  and  consequently,  their  ac- 
tion is,  as  I  have  already  observed,  (498)  at  right  angles  with 
the  action  of  the  longitudinal  fibres.  2d.  When  either  the  abso- 
lute, or  relative  strength  of  the  circular  fibres  is  increased  by 
any  cause  whatever,  labour  does  not  advance ;  therefore,  the  cir- 
cular fibres  do  not  directly  contribute  to  the  expulsion  of  the 
child.  3.  As  the  circular  fibres  do  not,  from  the  very  nature 
of  their  action,  contribute  to  the  immediate  propulsion  of  the 
child,  as  just  declared,  they  must  be  considered  inferior  in  powej. 
to  the  longitudinal  fibres ;  since,  the  child  is  expelled  without 
their  direct  agency— therefore,  the  latter  set  of  fibres  has  not 
only  to  move  the  child,  but  to  overcome  the  resistance  the  former 
gives,  by  the  direction  of  their  action.  We  see  this  finely  ex- 
emplified in  those  cases,  where  the  waters  have  been  discharged 
early,  and  the  uterus  closely  embraces  the  child ;  and  where,  by 
virtue  of  its  tonic  contraction,  it  even  accommodates  itself  to  the 


ISO        THE  MANNER  IN  WHICH  THE  OS  UTERI  IS  OPENED. 

inequalities  presented  by  the  child's  body ;  in  such  instances,  la- 
bour would  be  stationary,  did  not  the  longitudinal  fibres  possess 
greater  power,  than  the  circular. 


CHAPTER  XIII. 

THE  MANNER  IN  WHICH  THE  OS  UTERI  IS  OPENED. 

509.  With  these  facts  before  us,  I  shall  attempt  the  explana- 
tion of  the  dilatation  of  the  os  uteri.  At  the  full  period  of  utero- 
gestation,  the  process  called  labour  must  take  place,  that  the 
womb  may  expel  its  contents;  to  this  important  end,  its  body  and 
fundus  must  contract,  while  its  neck  must  dilate— the  question  now 
is,  how  is  the  latter  effected?  During  the  whole  period  of  gesta- 
tion, the  lower  part  of  the  womb  is  kept  closed  by  the  contraction 
of  the  circular  fibres:  this  condition  must  now  be  overcome  by  the 
exertions  of  the  longitiidinal;  therefore,  these  two  sets  of  fibres 
may,  without  a  strained  comparison,  be  considered  as  antagoniz- 
ing powers.  During  gestation,  at  least  until  the  seventh  month, 
the  longitudinal  fibres  yield  much  more  willingly  than  the  circular, 
to  the  distending  force  of  the  increasing  ovum;  this  may  be  owing 
to  their  greater  length,  or  their  greater  laxity;  and  hence,  per- 
haps, the  lengthened  form  of  the  uterus.  This  stretching  must 
have  a  limit,  or  a  maximum;  and  when  this  arrives,  they  will 
necessarily  be  stimulated  to  contraction;  and  this  really  takes 
place  at  this  period,  as  I  have  several  times  declared,  and  at- 
tempted to  prove,  (488,  500. )  Now,  the  effect  of  this  effort,  which 
is  almost  constantly  repeated  after  it  is  once  commenced,  is  felt  by 
(until  now,)  the  passive  neck  of  the  uterus;  and  obliges  it  not  only 
to  support  the  action  of  the  body  and  fundus,  but  also  the  weight 
of  the  child  and  waters;  these  joint  powers  make  it  unfold  itself, 
and  to  become  identified  with  the  other  portions  of  the  uterus;  so 
that,  at  full  time,  it  forms  a  portion  of  that  globe  which  is  placed 
in  the  cavity  of  the  pelvis;  and  its  distinctive  mark,  or  projec- 
tion, is  lost  in  the  uniform  surface  presented  to  the  finger. 

510.  From  the  moment  the  neck  begins  to  be  operated  upon,  it 
begins  to  lose  in  thickness,  and  in  length — and  these  changes  com- 
mence at  that  part  next  to  the  body  of  the  uterus;  so  that  the 


THE  MANNER  IN  WHICH  THE  OS  UTERI  IS  OPENED.  181 

extremity  of  the  neck,  or  the  os  tinccc,  is  the  last  portion  which  is 
effaced.  When  the  longitudinal  fibres  act,  the  circular  become  a 
little  stretched,  in  consequence  of  the  length  of  the  uterus  being 
diminished;  and  I  have  already  said,  (49S,)  that  the  uterus  can- 
not diminish  in  one  direction  while  the  membranes  are  entire,  with- 
out increasing  in  another;  and  this  must  be  the  case  so  long  as  the 
mouth  of  the  uterus  remains  shut;  but  this  cannot  be  very  long, 
as  it  is  obliged  to  sustain  the  whole  pressure  of  the  contents  of  the 
body  and  fundus,  and  this  in  proportion  to  the  power  with  which 
the  longitudinal  fibres  may  contract,  as  well  as  the  force  exerted 
by  a  part  of  the  circular  fibres,  which  are  now  called  into  action, 
by  the  contraction  of  the  longitudinal  distending  them,  until  they 
themselves  contract  from  this  very  stimulus. 

511.  This  action  and  re-action,  are  reciprocated  for  some  time; 
the  longitudinal  fibres  shortening  the  uterus  from  fundus  to  mouth; 
while  the  circular  attempts  to  resist  the  effect  of  their  action,  by 
contracting  themselves,  and  thereby  opposing  the  tendency  to  dis- 
tention in  the  transverse  direction  of  this  body — the  effect  of  this 
compound  action  is,  to  direct  the  body  to  be  moved  towards  that 
part  which  offers  it  the  least  resistance;  and  this  is  the  small  open- 
ing called  the  os  uteri — the  fibres  which  immediately  surround 
this  opening,  and  oppose  its  immediate  dilatation,  gradually  be- 
come weakened  by  the  superior  strength,  and  persevering  action 
of  the  longitudinal  fibres;  and  after  a  struggle  of  more  or  less  se- 
verity and  duration,  they  are  obliged  to  yield;  and  in  their  quies- 
cence, the  dilatation  of  the  os  uteri  consists. 

512.  In  the  whole  of  this  arrangement,  we  see  no  necessity  for 
the  mechanical  wedge-like  agency  of  the  membranes  acting  on 
the  circle  of  the  os  uteri,  which  Dr.  Denman*  speaks  of  as  im- 
portant to  its  dilatation — for  every  day's  experience  proves  that 
the  most  perfect  and  speedy  relaxation  of  the  mouth  of  the  uterus 
takes  place,  without  any  such  influence.  Indeed  the  doctor!  seems 
to  yield  this  point  when  he  confesses  that  "in  many  cases  the 
membranes  break  spontaneously  long  before  this  period  (that  of 
the  OS  uteri  being  wholly  dilated,)  without  any  material  inconve- 
nience." 

513.  If  it  be  asked,  why  are  those  labours  in  which  the  mem- 
branes give  way  early,  always  more  tedious  and  painful,  than 
those  in  which  they  are  preserved? 

*  Introduction,  Francis's  cd.  p.  278.  f  Idem,  p.  280. 


182         THE  MANNER  IN  WHICH  THE  OS  UTERI  IS  OPENED. 

514.  I  would  answer,  that  this  is  not  by  any  means  always  the 
case;  and  that  when  the  membranes  have  yielded  from  their  deli- 
cacy before  the  genuine  expulsive  action  has  commenced,  the 
uterus  may  be  said  to  be  surprised,  (if  I  may  use  the  expression,) 
into  contraction,  before  the  natural  stimulus  is  given.  In  conse- 
quence of  this,  the  uterus  is  made  to  embrace  the  child  closely,  by 
virtue  of  its  tonic  power,  and  is  sometimes,  by  this  event  thrown 
into  irregular  and  painful  contractions,  by  the  unequal  surface 
which  the  child's  body  presents  to  its  internal  surface — for  the 
evacuation  of  the  waters  prevents  the  lower  part  of  the  uterus 
from  being  fully  stretched  by  the  contractions  of  the  body  and 
fundus;  and  by  this  means,  retards  the  weakening  of  the  circular 
fibres  at  this  part;  a  circumstance  of  considerable  moment  to  the 
dilatation  of  the  os  uteri.  If  an  unusual  degree  of  pain  be  excited 
by  the  premature  escape  of  the  waters,  it  is  not  because  the  mem- 
branes and  waters  fail  in  their  v/edge-like  agency  to  dilate  it;  but 
because  the  uterus  is  prematurely  excited  into  action ;  and  of 
course,  before  all  the  terms  of  pregnancy  have  been  complied 
■vvith — as  the  waters,  while  retained,  serve  to  ensure  an  equal  dis- 
tention of  that  part  of  the  uterus,  which  we  have  agreed  to  call 
in  the  unimpregnated  state,  its  neck,  and  is  the  part  which  is  to 
relax  during  labour,  that  the  child  may  escape  from  the  general 
cavity  of  this  organ. 

515.  I  am  abundantly  confirmed  that  this  is  the  true  explana- 
tion; for,  by  the  fact,  if  the  waters  have  not  prematurely  passed 
ofif ;  or,  in  other  words,  if  at  the  time  of  their  escape,  the  uterus  is 
prepared  for  the  regular  routine  of  labour,  the  mere  circumstance 
of  their  evacuation,  (cseteris  paribus,)  will  neither  materially  re- 
tard the  dilatation  of  the  os  uteri,  nor  necessarily  create  unusual 
delay  to  delivery — of  this,  we  have  additional  proof  from  Dr.  Den- 
man,  as  just  quoted.  But  in  this  admission,  let  it  be  recollected, 
that  I  consider  the  waters  as  useful,  by  their  equal  pressure  upon 
the  lower  part  of  the  uterus,  and  by  distending,  and,  at  the  same 
time,  by  the  same  agency,  weakening,  the  circular  fibres  of  this 
part;  and  thus  indirectly  favouring  the  dilatation  of  the  mouth  of 
the  uterus. 

.  516.  I  may  therefore,  I  believe,  safely  lay  it  down  as  a  general 
rule,  that  the  early  spontaneous  rupture  of  the  membranes  does 
not  directly  or  necessarily  produce  a  more  painful  or  tedious  la- 
bour, unless  the  uterus  is  from  this  cause  immediately  excited  to 
contraction ;  for  should  pain  not  follow  very  soon,  or  should  the 


THE  MANNER  IN  WHICH  THE  OS  UTERI  IS  OPENED.  183 

legitimate  pains  of  labour  have  preceded  this  accident,  the  labour 
will,  all  things  being  equal,  be  as  in  ordinary  cases;  for  I  have 
many  times  seen  patients,  with  whom  the  first  intimation  of  labour 
being  at  hand,  was  a  discharge  of  the  liquor  amnii;  but  this  not 
instantly  followed  by  pain;  but  when  pain  did  come  on,  the  labour 
was  speedily  finished — in  these  instances,  the  mouth  of  the  uterus 
opened  as  speedily  and  as  extensively,  as  though  the  membranes 
had  not  given  way,  and  the  waters  had  not  discharged  themselves. 

517.  Let  any  one  who  has  made  the  attempt  to  penetrate  the 
OS  uteri  when  rigid,  be  asked,  if  a  direct  action  on  its  edges  by  tl->e 
hand  formed  in  a  wedge-like  shape,  and  the  application  of  consi- 
derable force  will  always  be  sufficient  to  overcome  the  opposition 
of  the  circular  fibres  of  the  neck?  He  will  answer,  if  he  be  candid, 
No;  and  will  add,  that  the  part  would  suffer  laceration  rather 
than  yield  to  the  force  employed.  Is  it  reasonable,  then,  to  expect 
that  a  wedge  formed  by  the  smooth,  and  comparatively  delicate 
membranes  with  the  liquor  amnii  within  them,  will,  as  a  mere 
mechanical  power,  however  aided  by  a  strongly  contracting  body 
and  fundus,  achieve  more  than  the  well-directed  force  of  the  hand 
as  just  stated?*  Let  any  one  familiar  with  the  general  manner 
in  which  the  distended  membranes  offer  themselves  at  the  orifice 
of  the  uterus  during  pain  be  asked,  if  their  presence  and  agency, 
at  such  a  moment,  presents  to  his  mind,  the  idea  of  a  mechanical 
power,  attempting  to  overcome  the  resistance  offered  by  the  con- 
traction of  the  circular  fibres?  and,  I  am  sure,  he  would  unhesi- 
tatingly say.  No. 

518.  When  the  os  uteri  does  dilate,  it  is  not  by  its  edges  being 
stretched  mechanically — it  is  an  absolute  inability  in  the  circular 
fibres  to  maintain  a  state  of  contraction,  and,  for  the  time  being, 
may  be  considered  as  paralyzed,  or  excessively  fatigued — or,  per- 
haps, more  properly  speaking,  it  is  the  relaxation  of  a  sphincter 
not  subject  to  the  control  of  the  will. 

519.  I  admit,  that  the  os  uteri  is  sometimes  forced  to  open  in  a 

*  Besides,  every  accoucheur  knows,  that  in  many  instances  of  the  most  spee- 
dy and  perfect  dilatation  of  the  os  uteri,  the  membranes  are  too  feeble  to  bear 
the  slightest  force.  The  mere  touch  of  the  finger  will  sometimes  rupture  them; 
and  this  at  the  moment  the  os  uteri  is  yielding  rapidly.  Now,  in  such  cases, 
the  dilatation  of  the  os  uteri  should  cease,  as  soon  as  the  membranes  had  yield- 
ed, if  their  presence  were  mechanically  necessary  to  this  end;  especially,  if  a 
portion  of  the  cliild  have  not  engaged  in  the  mouth  of  the  uterus,  to  supply  the 
place  of  the  distended  membranes. 


184         THE  MANNER  IN  WHICH  THE  OS  UTERI  IS  OPENED. 

degree,  by  the  membranes,  or  the  presenting  part  engaging  in  its 
circle  when  these  parts  are  strongly  impelled  by  the  contractions 
of  the  body  and  fundus;  but,  when  this  happens,  the  orifice  does 
not  present  the  same  feel  as  when  it  dilates  by  the  regular,  and 
natural  process?  it  is  evidently  perceived  that  it  is  reluctantly 
yielding  to  force,  and  is  not  obeying  a  law. 

520.  When  labour  is  most  easily,  and  naturally  performed,  there 
appears  to  be  a  tacit  understanding,  if  we  may  be  allowed  the 
expression,  between  the  longitudinal  and  circular  fibres;  the  latter 
relax  suddenly,  and  extensively;  while  the  former,  contract  so 
silently,  but  so  effectually,  that  we  cannot  discover  the  agencies 
by  which  this  is  effected — who  has  not  witnessed  the  almost  in- 
stantaneous opening  of  the  os  uteri?  been  sensible  of  the  retraction 
of  its  edges  over  the  child's  head,  and  the  delivery  of  the  child 
follow  almost  at  the  same  moment  ? 

521.  To  the  explanation  just  given  of  "the  manner  in  which 
the  OS  uteri  becomes  opened,"  it  is  objected,  "that  if  a  muscular 
part  is  suddenly  extended,  its  contractile  powers  are  brought  into 
violent  action;  but  let  the  part  be  extended  graduall)^,  as  is,  of 
course,  the  case  where  the  extension  depends  upon  the  slowly  in- 
creasing size  of  the  ovum,  and  when  it  has  arrived  at  its  '  maxi- 
mum of  stretching,'  its  antagonistic  powers  appear  to  be  destroyed ; 
for  contraction  either  does  not  take  place  at  all,  or  very  imper- 
fectly. It  is  well  known  that  surgeons  act  upon  this  principle, 
when  they  have  to  overcome  the  obstinate  contraction  of  muscles: 
they  exhaust  the  powers  of  the  part,  by  keeping  up  a  gradual  ex- 
tension."* 

522.  The  objection  just  stated,  is  ingenious,  but  not  valid:  1st, 
because  there  is  no  analogy  between  the  inordinate  stretching  of 
a  muscle  not  organized  for  this  purpose,  and  the  expansion  of  the 
uterus,  to  which  this  capacity  is  most  amply  given;  2d,  that  a  pe- 
riod must  arrive,  in  the  stretching  of  even  the  common  muscles, 
however  gently  performed,  at  which  they  would  contract,  and  that 
violently,  if  permitted  from  the  stimulus  which  "extension"  must 
offer;  and  it  is  precisely  so,  with  the  uterus — its  organization  is 
such,  as  to  support  a  great  deal  of  distention,  before  it  is,  like  the 
common  muscle,  stimulated  to  contraction;  3d,  the  bladder  is  gra- 
dually distended,  by  the  percolating  urine,  until  its  parietes  are 
put  upon  an  easy  stretch;  it  then  gives  warning,  that  it  can  no 

*  Lond,  Med.  and  Pbys.  Jour,  for  August,  p.  143. 


CONDUCT  DURING  LABOUR.  185 

longer  support  this  state  with  impunity;  for  the  distention  has  ar- 
rived at  its  healthy  ''  maximum,"  and  must  not  be  carried  farther; 
4th,  that  were  the  bladder,  or  the  uterus  itself,  suddenly  stretched 
to  the  extent  of  their  capacity,  they  would  as  certainly  lose  the 
power  of  contraction,  as  the  muscles  over  which  the  surgeon 
exerts  his  control. 


CHAPTER  XIV. 

CONDUCT  DURING  LABOUR. 

523.  In  the  management  of  labours  much  judgment  and  cau- 
tion are  required,  that  a  simple  and  natural  case,  may  not  be  con- 
verted into  a  laborious,  and  dangerous  one.  Ill-directed  measures 
will  always  have  penalties  attached  to  them;  and  it  is  only  by 
taking  a  proper  view  of  the  nature  of  the  labour,  that  it  can  be 
conducted  to  a  happy  issue.  There  is  no  one  circumstance,  that 
so  largely  and  certainly  contributes  to  divert  nature  from  her 
proper  course,  as  the  persuasion  that  art  can  always  benefit  her 
— hence,  the  constant  employment  of  ill-directed  mancBuvres  by 
an  ignorant  accoucheur,  or  midwife.  And  unfortunately  for  the 
interest  of  humanity,  it  requires  more  knowledge  not  tobeofficioiis 
than  falls  to  the  share  of  many  of  those,  who  pretend  to  practise 
midwifery.  It  is  a  vulgar  prejudice,  that  great  and  constant  be- 
nefit, can  be  derived  from  the  agency  of  the  accoucheur;  es- 
pecially, during  the  active  state  of  pain;  and  this  feeling  is  but  too 
often  encouraged  by  the  ignorant  and  the  designing,  to  the  injury 
of  the  patient,  and  to  the  disgrace  of  the  profession.  When  all 
things  are  doing  well,  the  active  duties  of  the  accoucheur,  are 
limited  indeed — it  is  but  where  the  cojitrary  obtain,  that  he  can 
be  said  to  be  positively  useful;  but  to  discriminate  between  the 
two  conditions,  requires  a  thorough  knowledge  in  what  a  healthy 
labour  consists;  and  this  can  only  be  known  with  certainty,  by 
him  who  is  well-grounded  in  the  principles  of  his  professicm, 
and  who  has  enjoyed  an  extensive,  or,  at  least,  a  well-directed 
experience. 

524.  To  conduct  a  labour  with  safety,  the  practitioner  should 

24 


186  CONDUCT  DURING  LABOUR. 

be  well  acquainted  with  its  phenomena;  the  order  or  succession 
of  them;  be  able  to  decide,  when  certain  of  them  are  wanting,  or 
when  others  are  in  excess;  to  estimate  the  relative  or  positive  im- 
portance of  such;  ihe  force  or  effect  of  each  pain ;  the  necessity  of 
preserving  or  of  wasting  the  waters;  the  degree  of  resistance  the 
OS  uteri,  or  external  parts  may  offer;  the  situation  of  the  former, 
as  regards  the  presenting  part ;  the  certainty  of  the  presentation, 
both  generically  and  specifically  ;  the  mode  of  rectifying  any  er- 
ror of  presentation  in  proper  time  ;  the  capability  of  doing  this 
with  the  greatest  advantage  to  the  patient  and  to  the  infant;  and 
"  though  last,  not  least"  in  importance,  he  should  be  able  to  pur- 
sue a  firm,  candid,  and  feeling  conduct  throughout  the  whole 
scene,  that  he  may  not  be  betrayed  into  indiscretion,  by  the  over- 
weening anxiety  of  the  friends  of  the  patient;  that  he  may  not 
lose  the  important  moment  to  act,  from  an  apprehension  that 
blame  may  attach  upon  the  disclosure  of  its  necessity;  and  that 
the  sufilsrer  may  derive  every  advantage  his  kindness  and  sympa- 
thy can  aflTord. 

525.  That  man  is  but  little  used  to  the  exercise  of  the  social 
virtues,  who  is  ignorant  of  the  influence,  a  kind  and  feeling  con- 
duct has  upon  his  suffering  patient — to  her,  it  almost  atones  for 
the  want  of  skill  or  experience:  and  to  deprive  her  of  it,  is  with- 
holding a  right  for  which  nothing  can  compensate. 

526.  She  is  entitled  to  all  the  consolation  a  well-grounded  as- 
surance of  a  happy  termination  of  her  sufferings  can  afford;  and 
this  must  be  offered  to  her  from  time  to  time,  that  she  may  profit 
by  its  encouraging  influence;  yet  sbe  must  not  be  betrayed  into 
false  hopes,  by  an  ill-judged  promise  of  a  speedy  issue,  when  the 
period,  from  the  very  nature  of  the  case,  must  be  remote — no- 
thing perhaps  is  so  destructive  to  confidence,  as  ill-requited  pro- 
mises of  this  kind  ;  nothing  so  sickening  to  the  heart,  as  "  hope 
deferred." 

527.  The  young  practitioner  especially,  should  be  very  sparing 
of  promises;  for  it  requires  long  experience  to  make  them  with 
any  kind  of  certainty;  and  until  he  possess  this,  they  should  be 
evasively  given,  that  sad  disappointment  may  not  ensue.  For  a 
woman  will  support  herself  with  much  firmness,  where  relief  is 
believed  to  be  certain,  tliough  it  may  be  distant,  while  she  would 
flag,  under  the  failure  of  often  repeated  promises  of  speedy  re- 
lief.* Her  mind  should  be  kept  as  free  from  anxiety  as  the  nature 

*  Denman. 


CONDUCT  DURING  LABOUU.  187 

of  hdf-  siluMttm  will  permit;  therefore,  no  conversation  should  be 
inthi1^<^(j_HiV  tf^nt  miglit  for  an  instant  excite  her  apprehensions 
— conversati'^on~"5hTTOitWje-xlieeiful^nd  free  from  the  idle  dis- 
cussions of  danger  in  similar  situations;  and  it  TnuBUafi.as_void  of 
levity,  as  of  gloom.  "^ 

528.  To  the  well-bred  gentleman,  it  would  be  almost  an  insult 
to  say  anything  on  the  score  of  decency;  but  as  errors  may  be  un- 
consciously committed,  it  may  be  proper  to  suggest  a  few  cau- 
tions upon  this  head  that  may  be  important  to  the  welfare  of  the 
well-meaning,  but  inexperienced  practitioner. 

529.  1st.  Let  all  communications  to  the  patient  of  a  deUcate 
nature,  be  conducted  through  the  medium  of  a  third  person;  the 
nurse  when  present,  should  always  be  that  person ;  in  her  ab- 
sence, an  elderly  friend. 

530.  2d.  Endeavour,  by  a  general  and  well-chosen  conversa- 
tion, to  divert  the  patient's  mind  as  much  as  possible  from  the 
purpose  of  your  visit,  when  your  services  are  not  immediately 
required. 

531.  3d.  When  your  presence  is  not  absolutely  necessary  in 
the  sick  room,  be  as  little  in  it  as  will  be  consistent  with  your 
duty — by  this  you  remove  restraint;  and  abridge  to  appearance 
the  period  of  your  watching. 

532.  4th.  Should  you  judge  it  necessary  to  ascertain  the  situa- 
tion of  your  patient,  let  the  proposition  be  made  by  a  third  per- 
son, as  the  nurse;  let  her  declare  the  circumstances  which  lead 
you  to  believe  it  would  be  important;  such  as  the  length  of  time 
the  patient  has  been  in  pain;  the  force  and  frequency  of  the  pains; 
the  evacuations  of  the  waters,  if  it  have  taken  place;  and  above 
all,  the  necessity  of  ascertaining  the  progress  of  the  labour,  and 
the  nature  of  the  presentation. 

533.  5th.  If,  after  you  have  made  your  examination,  you 
should  be  importuned  for  your  opinion  of  the  nature  of  the  pre- 
sentation, and  the  duration  of  the  labour,  do  not  commit  your- 
self by  any  positive  declaration,  unless  you  are  certain  of  the 
first,  and  pretty  sure  of  the  latter. 

534.  6th.  Before  you  proceed  to  the  examination,  let  your 
patient  be  placed  with  the  most  scrupulous  regard  to  delicacy, 
as  the  slightest  exposure  is  never  necessary;  let  the  light  be  ex- 
cluded from  the  room  by  closing  the  shutters  if  it  be  day,  and 
by  the  concealment  of  it,  if  it  be  night.  So  much  for  the  regula- 
tion of  the  conduct  of  the  accoucheur  in  his  intercourse  with  his 


188  CONDUCT  DURING  LABOUR. 

patient;  but  it  is  also  important  that  we  lay  down  some  general 
rules  by  which  he,  and  the  patient  shall  be  governed,  during  the 
progress  of  the  labour. 

535.  1st.  The  patient  is  to  be  forbidden  everything  which 
shall  have  a  tendency  to  excite  the  system;  she  will  therefore 
be  prohibited  wine  or  any  other  liquor;  or  even  stimulating 
food. 

536.  2d.  She  should  be  directed  to  keep  as  quiet  as  possible; 
and  the  preposterous  custom  of  obliging  her  to  walk  the  floor 
with  a  view  to  increase  the  pains  when  tardy,  should  be  peremp- 
toril}^  forbidden. 

537.  3d.  Inquiry  should  be  made  as  to  the  state  of  the  bowels; 
costiveness  should  be  removed  by  castor  oil,  magnesia,  or  any 
other  mild  cathartic,  if  there  appears  to  be  sufficient  time  for  its 
operation;  if  not,  let  it  be  effected  by  a  simple  injection.* 

538.  4th.  Her  dress  should  be  such,  as  to  require  no  alteration 
after  delivery;  therefore,  her  linen  should  be  so  placed,  as  to  be 
out  of  danger  of  becoming  wet  from  the  discharges;  her  petti- 
coat should  be  without  shoulder-straps,  that  it  may  be  easily  re- 
moved; and  a  bed  gown  should  protect  the  upper  part  of  her 
body. 

539.  5th.  The  bed  should  be  so  arranged  as  to  preserve  it  with 
certainty  from  the  discharges;  for  this  purpose  a  blanket  should 
be  folded  several  times,  and  placed  beneath  the  under  sheets  at 
the  part  of  the  bed  on  which  the  woman  will  permanently  lie;  a 
sheet  as  often  folded  should  be  placed  over  the  under  sheet,  so  as 
to  correspond  with  the  blanket  below ;  on  this  the  woman  will 
be  placed  after  delivery. 

540.  6th.  The  woman  will  be  placed  for  labour  upon  her  left 
side,  at  the  foot  of  the  bed,  in  such  a  manner,  as  will  enable  her 
to  fix  her  feet  firmly  against  the  bed-post;  her  hips  within  ten  or 
twelve  inches  of  the  edge  of  the  bed ;  her  knees  bent,  her  body 
well  flexed  upon  the  thighs ;  this  position  will  bring  the  head 
and  shoulders  near  the  centre  of  the  bed ;  and  pillows  may  be 
placed  to  raise  them  to  a  comfortable  height — the  part  of  the  bed 
on  which  the  patient  is  now  placed,  must,  like  the  part  on  which 
she  is  permanently  to  rest,  be  secured  by  folded  blankets  placed 
over  the  under  sheet. 

*  A  pint  of  warm  watei",  and  a  table  spoonful  of  common  salt  is  one  of  the 
best. 


CONDUCT  DURING  LABOUR.  189 

541.  7th.  When  the  patient  is  gibout  to  be  placed  for  labour, 
the  practitioner  should  withdraw,  and  leave  this  arrangement  to 
the  nurse ;  she  should  be  covered  entirely,  except  her  head ;  if 
in  winter,  by  a  blanket  or  coverlet ;  if  in  summer  a  sheet  will 
be  sufficient. 

542.  8th.  When  about  to  make  an  examination,  choose  the 
time  of  a  pain  for  this  purpose,  and  to  proceed  to  it  with  the  most 
rigid  observance  of  delicacy.  To  the  very  young  practitioner  it 
may  be  well  to  observe,  that  the  chair  on  which  he  is  about  to  sit, 
should  be  so  placed  that  his  right  arm  should  be  next  to  his  pa- 
tient: if  this  be  not  attended  to,  his  position  will  be  both  incon- 
venient and  fatiguing. 

543.  9th.  Do  not  remain  with  the  patient  longer  than  the  state 
of  the  labour  may  make  it  necessary.  That  is,  if  it  be  not  well- 
advanced,  time  should  be  given  for  its  farther  progress ;  but  from 
time  to  time,  it  is  well  to  ascertain  its  condition ;  but  beware  of 
officious  and  unnecessary  touching,  for  the  reason  we  have  else- 
where assigned.  (494.) 

544.  10th.  Should  the  pains  be  efficient,  and  the  os  uteri  well 
dilated,  or  even  easily  dilatable,  and  the  membranes  entire,  let 
them  be  ruptured  by  the  pressure  of  the  finger  against  them,  or, 
by  cutting  them  with  the  nail  of  the  introduced  fmger.  We  are 
well  aware  that  this  direction  is  very  far  from  being  in  conformity 
with  the  opinions  of  writers  upon  this  subject;  but  we  are  sure, 
we  have  not  adopted  it  upon  slight  grounds;  nor  proposed  it,  be- 
cause it  might  quadrate  with  preconceived  notions.  In  directing 
it,  we  are  certain  that  experience  is  altogether  in  its  favour. 
And  this  should  be  done  for  the  following  reasons:  first,  because, 
when  the  mouth  of  the  uterus  is  dilated,  or  even  easily  dilatable, 
the  membranes  have  performed  every  duty  they  can  perform ; 
secondly,  that  very  often  the  advancement  of  the  presenting  part 
is  retarded  by  the  strength  of  the  membranes,  and  the  labour 
much  protracted  by  it;  thirdly,  that  very  frequently  the  pains  are 
increased  both  in  force  and  frequency,  and  the  labour  much 
abridged  by  it;  fourthly,  it  gives  much  greater  security  to  the 
woman  after  delivery,  by  permitting  the  tonic  contraction  to  take 
place  before  it  is  accomplished,  and  thus  insuring  a  more  speedy 
delivery  of  the  placenta,  and  also  very  much  lessening  the  risk 
of  after-haemorrhage. 

545.  11th,  When  the  head  is  emerging  from  under  the  arch  of 
the  pubes,  the  perineal  tumour  should  be  carefully  supported  by 


190  OP  THE  NECESSARY  DUTIES  TOWARDS  THE  CHILD. 

placing  the  palm  of  the  left  hand,  with  a  cloth  interposing  against 
it,  and  retained  there  until  the  head  is  entirely  freed  from  the 
vulva. 

546.  12th.  When  the  head  is  in  this  situation,  it  should  not  be 
meddled  with;  no  effort  should  be  made  to  withdraw  the  body  of 
the  child;  its  delivery  should  be  trusted  to  the  subsequent  con- 
tractions of  the  uterus,  that  this  organ  need  not  be  too  suddenly 
emptied,  and  by  this  means,  give  rise  to  floding. 

Sect.  I. — Of  the  Necessary  Duties  towards  the  Child. 

547.  Having  conducted  the  labour  to  the  delivery  of  the  child, 
new  duties  immediately  commence;  the  high  importance  of 
which,  renders  it  proper,  we  should  lay  down  some  rules  for  their 
fulfilment. 

548.  The  first  great  object  after  the  delivery  of  the  child,  is 
to  establish  respiration;  for  the  most  part  this  takes  place  spon- 
taneously the  instant  it  is  in  the  world;  indeed  it  very  often  cries, 
even  forcibly,  so  soon  as  the  head  is  protruded  through  the  exter- 
nal parts.  M.  Baudelocque  has  communicated  to  the  Academy 
of  Sciences,  a  case  of  Labour,  in  which  the  waters  being  evacua- 
ted, the  face  of  the  child  presented  to  the  neck  of  the  uterus,  and 
the  child  uttered  cries  as  strong  as  if  it  had  been  delivered.  Ame- 
rican Journal  of  the  Medical  Sciences  for  May,  1831.  p.  248. 
But  if  it  fail  to  cry  soon  after  delivery,  attention  should  be  imme- 
diately paid,  that  respiration  may  be  established.  The  child  may 
be  born  in  one  of  the  following  conditions.  1st.  Feeble,  (but  not 
entirely  exhausted,)  either  by  the  delay  in  its  delivery;  by  the 
compression  of  the  cord;  or  from  a  delicacy  of  stamina;  these 
several  conditions  may  be  attended  by  a  pulsating  cord,  or  one  in 
which  pulsation  has  ceased. 

549.  In  cases  in  which  the  cord  still  pulsates,  there  is  but  little 
risk,  so  long  as  this  action  continues;  and  for  the  most  part,  all 
that  is  necessary  is,  to  remove  all  impediments  from  the  mouth 
of  the  child  which  may  interrupt  the  passage  of  air  to  the  lungs; 
or  by  dashing  upon  its  body  some  cold  spirits  or  brandy.  This 
almost  instantly  makes  it  send  forth  cries,  that  are  most  welcome 
to  the  accoucheur,  and  are  the  reward  of  the  suffering  mother. 
But  should  there  be  no  pulsation  in  the  cord;  the  body  flaccid  ; 
and  especially,  if  upon  dividing  the  funis,  only  a  drop  or  two  of 
black  blood  issues  from  the  cut,  the  case  is  desperate  ;  but  not  al- 
ways absolutely  hopeless. 


OF  THE  NECESSARY  DUTIES  TOWARDS  THE  CHILD.  191 

550.  In  this  case  we  should,  1st,  carefully  remove  any  mucus 
that  may  be  in  the  mouth,  fauces,  or  upper  part  of  the  trachea, 
by  wiping  as  far  as  we  can  reach  with  the  little  fmger  armed  with 
a  piece  of  fine  dry  rag;  2d,  endeavour  to  inflate  the  lungs  of  the 
child  by  forcing  air  into  them  from  our  own;  this  must  be  done 
by  holding  the  nostrils  and  applying  our  mouth  to  that  of  the 
child,  and  forcibly  expiring.*     If  we  succeed  in  passing  air  into 

*  M.  Velpeau  recommends  this  to  be  done  by  means  of  "a  quill  barrel,  a  female 
catheter,  or  any  kind  of  canula,  introduced  into  the  moudi  or  nostrils,  or  by- 
blowing  with  the  mouth  directly  into  the  air  passages.  The  laryngeal  tube  in- 
vented by  Chausier,  having  the  advantage  of  pretty  exactly  filling  the  glottis 
when  introduced  into  it,  is  better  than  the  strait  canula  of  Heroldt;  but  a  simple 
giun  elastic  catheter,  an  instrument  which  can  be  got  anyiuhere,  is  almost  as  con- 
venient: it  is  introduced  through  the  mouth,  as  far  as  the  bottom  of  the  phai-ynx; 
then  while  it  is  passed  inwards,  the  point  may  be  bent  with  the  httle  finger,  so  as 
to  compel  it  to  enter  into  the  larynx  rather  than  the  oesophagus;  when  fixed 
right,  the  nostrils  and  mouth  of  the  fcEtus  are  closed,  and  the  inflation  com- 
menced. However,  if  it  should  be  admitted  that  the  experiments  tried  by 
Winslow,  Heroldt,  Schule,  Viberg,  Schmidt,  and  Beclard,  incontestibly  prove 
that  the  liquor  amnii  penetrates  during  intra-uterine  life  as  far  as  the  bronchia, 
it  would  be  useful  to  fi-ee  the  trachea  from  it  by  suction  or  otherwise,  previously 
to  trying  inflation ;  but  there  is  too  much  uncertainty  upon  this  point  for  it  to 
serve  as  a  basis  for  any  practice  whatever."  p.  564.  Dr.  Meig's  translation. 

We  rarely  meet  with  an  assemblage  of  directions  or  suggestions,  that  con- 
tain so  little  practical  utility,  as  we  do  in  the  above  quotations.  First,  the  kind 
of  instrument  to  be  used  upon  such  occasion  is  far  from  being  satisfactory;  for 
neither  the  quill,  nor  female  catheter,  nor  any  kind  of  canula,  can  be  used  with 
any  prospect  of  success,  unless  one  of  its  extremities  pass  into  the  trachea;  and 
this  requires  no  common  adroitness,  to  render  its  location  exact,  or  profitable. 
But  if  this  difficulty  be  surmounted  by  one  of  tliese  instruments,  we  are  every 
way  certain  that  violent  irritation  must  ensue,  especially  from  "the  quill  or  any 
kind  of  canula,"  and  this  we  fear  without  proportional  advantage;  for  we  doubt 
very  much  whether  the  lungs  can  be  inflated  by  these  means  without  the  em- 
ployment of  very  many  more  precautions  than  are  recommended  by  M.  Vel- 
]>eau.  Besides,  it  would  be  proper  to  put  every  practitioner,  but  especially 
the  young,  in  possession  of  means  that  can  always  be  commanded,  rather  thai\ 
to  make  him  rely  upon  instruments  for  this  common  purpose,  that  can  rarely  be 
procured;  but  at  the  loss  of  so  much  time  that  would  be  fatal  to  the  child — for 
the  loss  of  five  minutes  upon  such  occasions,  most  commonly  seals  its  fate. 
For  though  the  "gum  elastic  catheter  may  be  got  anywhere"  (that  is  any- 
where in  Paris)  the  child  would  often  lose  its  life,  were  it  required  to  be  sent 
for  out  of  the  house;  and  in  this  country,  nay  even  in  this  city,  much  time  would 
be  lost,  were  tliis  instrument  to  be  relied  upon.  The  apphcation  of  the  accou- 
cheur's mouth  to  that  of  the  child,  as  we  have  just  recommended,  is  the  only 
means  that  can  be  depended  upon  for  the  inflation  of  the  cliild's  lungs.  Second- 
ly; however  M.  V.  may  scout  the  idea  of  tlie  trachea  being  at  least  partially 
filled  with  the  Uquor  amnii,  and  disregard  the  precaution  of  removing  it,  we  do 
advance  upon  ow  own  proper  experience,  that  it  Is  an  accident  by  no  means  of 


192  OP  THE  NECESSARY  DUTIES  TOWARDS  THE  CHILD. 

the  child's  lungs,  which  is  easily  known,  by  the  elevation  of  the 
chest;  and  if  the  air  we  have  thrown  in,  is  not  immediately  re- 
turned, we  must  quickly  expel  it,  by  a  gentle,  but  pretty  firm 
pressure  upon  the  thorax;  3d,  by  placing  the  child's  mouth  down- 
ward, and  holding  the  body  and  hips  higher  than  the  head;  at 
the  same  time  gently  shaking  the  child,  so  as  to  disengage  any 
mucus  that  may  be  lodged  in  the  trachea:  and  permitting  it  to 
flow  from  the  mouth,  by  making  this  the  depending'part* — then 
cautiously  wiping  the  mouth  as  just  directed;  renew  the  infla- 
tions, and  the  suspensions  alternately,  until  the  mucus  flow  from 
the  mouth ;  by  proceeding  in  this  manner,  I  have  often  had  the 
satisfaction  of  seeing  the  child  restored,  under  very  discouraging 
circumstances.  It  is  every  way  worthy  of  remark,  that  owing  to 
the  tenacity  of  the  fluid  within  the  windpipe,  we  cannot  at  first 
force  air  into  the  lungs;  but,  by  a  little  perseverance,  we  over- 
come this  obstacle,  and  the  mucus  becomes  sometimes  so  thinned, 
as  to  flow  readily  from  the  mouth,  and  at  once  relieves  the  child — 
this  operation  should  never  be  neglected ;  nor  should  it  be  too 
soon  relinquished;  especially,  if  we  can  excite  a  few  pulsations  in 
the  heart  and  in  the  cord.  Both  of  these  should  be  carefully  ex- 
amined after  each  inflation ;  the  pulsation  of  the  heart  is  best 

uncommon  occurrence;  and  that  there  is  no  such  "uncertainty  upon  this  point," 
as  to  render  at  all  doubtful  the  practice  necessary  upon  such  occasions.  For 
we  do  further  aver  it  as  our  firm  opinion  and  belief,  that  we  have  saved  the 
lives  of  very  many  children  by  the  plan  recommended  in  our  text. 

»  We  regret  to  find  the  following  passage  in  Velpeau's  directions  for  the  treat- 
ment of  children  born  in  a  state  of  asphyxia—'*  there  is  no  reason  to  believe, 
that  it  is  either  safe  or  useful  to  turn  tlie  child  with  its  face  downwards  to  force 
the  matters  contained  in  the. trachea  to  escape  therefrom."  We  say  we  are 
sorry  to  observe  the  above  opinion  so  peremptorily  announced;  as  the  authority 
of  M.  Velpeau  might  lead  to  the  neglect  of  tliis  highly  important,  and  in  some 
instances,  this  indispensable  practice.  I  am  every  way  persuaded,  that  I  have 
preserved  the  lives  of  many  children  by  this  mode  of  management,  which  with- 
out it,  would  have  been  lost.  And  we  are  altogether  as  certain,  that  no  possible 
injury  can  arise  from  the  practice,  unless  it  be  from  mal-adroitness  in  the  hand- 
\mv  of  the  child.  We  are  also  persuaded  that  it  is  vastly  more  efficacious,  and 
to  say  the  least,  as  safe,  as  the  direction  he  gives  immediately  before  for  the  same 
piu-pose,  namely,  to  cleanse  the  mouth  by  a  brush  either  dry,  or  dipped  in  salt 
and  water,  and  indubitably  more  rational  and  efficient  than  the  one  that  follows; 
to  wit,  "supposing  the  secundines  are  either  wholly  expelled,  or  on  the  point 
of  being  expelled,  and  that  there  should  be  some  pulsation  in  the  cord,  I  should 
not  oljject  to  keeping  them  for  some  time  in  warm  wine  and  water".'.'  M.  \'. 
has  not  told  us  however,  how  the  wine  and  water  is  to  be  apphcd  to  the  uiicx- 
pelled  secundines. 


OF  THE  NECESSARY  DUTIES  TOWARDS  THE  CHILD.  193 

detected  by  placing  the  ear  immediately  over  its  region;  that  of 
the  cord,  by  pressing  it  between  the  thumb  and  finger,  close  to 
the  umbilicus,  4th.  By  the  frequent  application  of  heated  cloths; 
this  should  be  attended  to  immediately,  and  persevered  in  until 
the  last  moment  of  hope.  In  the  August  No.  of  the  Lond.  Med. 
and  Phys.  Jour,  we  find  the  following  notice,  of  a  method  to  resus- 
citate still-born  children,  which,  from  the  manner  it  is  announced, 
seems  to  be  considered  as  new  by  the  editor;  at  this,  we  are  not 
a  little  surprised  as  the  plan  has  been  recommended  for  many 
years  by  us,  both  in  our  public  and  private  lectures,  as  well  as  in 
the  first  edition  of  this  work.  Many  years'  experience  has  con- 
firmed the  efficacy  of  the  method,  though  we  lay  no  claim  to  the 
suggestion.  We  cannot  pretend  to  say,  at  this  moment,  from 
whose  recommendation  we  first  employed  it ;  but  we  are  certain, 
that  it  has  been  our  method  for  nearly  forty  years ;  and  that  we 
firmly  believe  we  obtained  it  at  second  hand.  But  this  is  of  no 
consequence.  Its  almost  uniform  success  renders  it  valuable;  and, 
if  it  be  not  generally  known,  (as  would  seem  to  be  the  case,  from 
the  position  it  occupies  in  a  widely  circulating,  and  highly  useful 
journal,)  it  ought  to  be;  especially,  as  agreeably  to  the  authority 
about  to  be  quoted,  it  has  succeeded  in  some  apparently  hopeless 
cases. 

"  Mr.  J.  Toogood,  of  London,  has  related  some  cases  in  which 
he  has  recovered  infants  apparently  dead,  after  an  unusual  length 
of  time.  In  one  case,  no  efibrt  was  made  to  respire  for  thirty-five 
minutes ;  in  another,  forty-five  minutes  had  elapsed ;  in  a  third, 
thirty  minutes;  and  in  a  fourth,  the  mother's  situation  was  so 
critical,  that  the  child  was  not  attended  to  for  more  than  half  an 
hour ;  it  had  been  wrapped  in  a  cloth  and  removed  to  another 
room.  An  attempt  was  immediately  made,  and  in  twenty-five 
minutes  signs  of  life  were  manifested ;  and  in  fifteen  more,  the 
child  breathed  freely.  Mr.  T.  has  always  succeeded  in  resuscita- 
ting infants  who  were  living  during  the  birth.  He  puts  no  con- 
fidence in  the  warm  bath,  in  frictions,  nor  in  pouring  stimulants, 
but  endeavours  to  imitate  natural  respiration,  by  placing  a  napkin 
over  the  mouth,  pressing  out  the  air  from  the  chest  afterwards. 
When  a  feeble  attempt  is  made  by  the  child  to  inspire,  the  infla- 
tion should  be  made  quicker;  and  afterwards  a  little  aq.ammonise 
or  brandy,  rubbed  over  the  palm  of  the  hand,  and  held  over  the 
mouth,  during  the  inflation  of  air,  will  materially  assist  the  re- 
covery. I  much  prefer  dry  warmth  as  an  application  to  the 
25 


194  OF  THE  NECESSARY  DUTIES  TOWARDS  THE  CHILD- 

child's  body,  to  the  warm  bath  which  is  so  much  relied  on  in 
such  cases;  I  think  the  latter  decidedly  injurious,  though  I  can- 
not pretend  to  explain  why.*  Might  not  a  properly  constructed 
syringe  be  highly  useful  in  removing  the  obstructing  mucus? 

551.  When  the  child  shows  signs  of  returning  life,  it  is  gene- 
rally by  a  deep  short  sob;  which  may  be  repeated  at  longer  or 
shorter  intervals ;  but  when  we  think  the  interval  too  long,  we 
should  renew  the  inflations,  &c.  Should  respiration  be  but  feebly 
restored,  we  should  carefully  guard  against  anything  like  fatigue 
to  the  child;  it  should  not  on  any  consideration  be  disturbed,  by 
dressing;  on  the  contrary,  it  must  be  carefully  placed  in  such  a 
situation,  as  will  permit  the  frequent  renewal  of  the  warm  appli- 
cations, which  are  of  primary  consequence  of  the  well-doing  of 
the  child.  I  have  had  more  than  once  the  mortification  to  see  all 
my  endeavours  frustrated,  by  inattention  to  my  directions  upon 
this  point,  though  given  as  impressively  as  I  well  knew  how. 

552.  2d.  The  ohikl  may  be  born  healthy  and  strong,  with  a 
brisk  pulsation  in  the  funis,  yet  not  cry;  because  a  mechanical 
obstruction  from  mucus  prevents  the  ingress  of  air  into  the  lungs. 
This  mucus  may  be  in  the  mouth  or  posterior  fauces,  or  it  may 
be  in  the  trachea — if  in  the  first,  we  may  remove  it  entirely  by  a 
piece  of  fine  rag  upon  the  little  finger,  as  just  suggested;  (550)  if 
in  the  second,  by  suspending  the  child  as  just  directed,  which 
will  seldom  fail  to  give  relief,  by  permitting  the  mucus  to  run 
from  the  mouth.  I  do  not  recollect  an  instance,  where  it  was 
necessary  to  have  recourse  to  inflation  if  the  pulsation  in  the  cord 
continued ;  but  if  it  stop  before  respiration  be  established,  recourse 
must  be  had  to  inflation.  When  the  child  is  about  to  make  at- 
tempts to  cry,  I  often  enable  it  to  succeed,  by  dashing  its  body 
with  spirit  or  brandy  as  directed  above. 

553.  3d.  The  child,  from  being  long  delayed  in  the  passage, 
or  from  having  its  neck  tightly  begirt  with  the  cord,  may  be  still- 
bornjt  in  this  case  its  face  will  be  black,  or  livid,  and  svvoln — the 

*  Does  the  warm  bath  invite  too  much  blood  to  the  capillaries  of  the  sui-face, 
and  thus  deprive  the  general  circulation  of  a  quantity  that  is  essential  to  the  well 
perfoi-mance  of  this  process  ? 

f  Very  little  attention  has  been  paid  until  lately  to  the  pathological  condition 
of  children  who  die  in  astate  of  asphyxia  in  coming"  into  the  world.  It  has  now 
atti-acted  the  attention  of  the  French  pathologists,  and  some  curious  facts  have 
presented  themselves,  especially  as  regards  the  state  of  the  liver.  Andi-alsays, 
"that  a  mechanical  cause  will  sometimes  produce  a  congestive  state  of  the  hver 
during  the  progress  of  a  laboui-,  and  in  those  children  who  die  in  a  state  of  as- 


OF  THE  NECESSARV  DTTTTES  TOWARDS  THE  CHILD.  195 

arteries  may  have  ceased  to  beat,  or  they  may  beat  vigorously — 
in  such  cases,  nothing  can  save  the  child  from  immediate  death, 
but  the  instant  abstraction  of  blood  by  cutting  the  cord — should 
the  pulsation  have  ceased,  we  may  sometimes  still  succeed  in 
drawing  some  blood  by  forcing  it  from  the  cord,  and  then  em- 
plojang  inflations,  &c. ;  if  pulsation  continue,  we  must  also  ab- 
stract blood  by  cutting  the  cord — the  quantity  to  be  drawn  must 
be  regulated  very  much  by  its  effects — when  respiration  is  esta- 
blished, we  need  draw  no  more;  but  until  some  signs  discover 
themselves  of  this  being  about  to  take  place,  we  may  abstract 
pretty  freely,  as  this  process  most  probably  is  interrupted  by  the 
congestive  state  of  the  brain,  which  can  only  be  removed  by  pret- 
ty ample  depletion. 

554,  When  respiration  is  established  either  spontaneously,  or 
by  artificial  means,  we  apply  a  ligature  to  the  cord,  provided 
pulsation  has  ceased  in  it;  but  not  until  then.  The  best  ligature 
is  a  portion  of  a  skein  of  fine  thread;  if  this  be  not  at  hand,  a 
piece  of  narrow  tape  or  flat  bobin  will  answer  perfectly  well — 
it  should  be  applied  an  inch  or  an  inch  and  a  half  from  the  um- 
bilicus, and  should  be  drawn  sufficiently,  to  make  it  securely 
tight — this  precaution  is  necessary,  as  otherwise  bleeding  some- 
times ensues.  We  are  aware,  that  it  is  considered  a  work  of 
supererogation  to  apply  a  ligature  to  the  cord,  by  some — but  this 
precaution  in  our  opinion  should  never  be  neglected;  for  it  is  not 
true  as  the  advocates  for  this  carelessness  declare,  that  "after  the 
child  has  breathed,  and  respiration  is  well  established,  the  circu- 
lation in  the  umbilical  arteries  never  returns ;"  for  we  have  re- 
peatedly witnessed  the  contrary.  We  have  witnessed  several 
nearly  fatal  instances  of  haemorrhagy  from  the  umbilicus,  where 
it  has  been  thought  that  the  vessels  had  been  properly  protected 
against  this  accident.  And  we  find  the  following  interesting 
case  rdated  by  Mr.  Waller,  in  the  London  Medical  and  Physical 
Journal  for  February,  1829,  Vol.  Ixi.  No.  360.  New  Series,  Vol. 
i.  No.  32,  p.  121. 

555.  "In  one  instance  there  was  repeated  haemorrhage  from  the 
umbilical  cord,  which  so  weakened  the  infant  that  it  died  in  a 
few  days.     This,  I  apprehend,  must  have  arisen  from  disease  of 

phyxia,  will  cause  a  rupture  of  the  hepatic  vessels;  and  from  excessive  engorge- 
ment an  effusion  is  found  on  the  convex  surface  beneatli  the  investing  mem- 
brane of  the  liver.  And  Billard  has  found  blood  effused  into  the  abdomen,  in  con- 
sequence of  this  engorged  state  of  this  organ. 


196  OF  THE  NECESSARY  DUTIES  TOWARDS  THE  CHILD. 

the  arteries,  as  there  was  no  less  than  six  ligatures  applied,  arid 
by  three  different  persons,  (myself  among  the  rest,)  notwith- 
standing which,  however,  the  bleeding  recurred  at  intervals,  and 
the  blood  was  observed  to  issue  not  from  the  part  at  which  the 
ligature  was  applied,  but  from  the  extremity  of  the  funis."  Is 
this  not  an  instance  of  a  constitutional  disposition  to  hemor- 
rhage rather  than  one  of  diseased  arteries?  The  cord  should  be 
cut  by  a  pair  of  scissors,*  half  an  inch  at  least  beyond  the  liga- 
ture— it  is  never  necessary  to  place  two  ligatures,  except  there 
be  twins — indeed,  it  is  best  not  to  do  so;t  as  the  evacuation  from 
the  open  extremity  of  the  cord  will  yield  two  or  three  ounces 
of  blood  sometimes,  which  favours  the  contraction  of  the  uterus, 

•  Formerly  many  prejudices  existed  on  the  subject  of  cutting  the  navel;  and 
even  the  instrument  with  which  this  should  be  performed.  Alphonse  Le  Roy 
is,  however,  the  only  modern  I  know,  who  seriously  recommends  attention  to 
this  point.  lie  directs,  that  "  we  shoidd  not  cut  the  cord,  but  when  the  pulsa- 
tion in  the  cord  has  nearly  ceased."  And  adds,  that,  "  as  regards  the  moderns, 
respecting  the  cutting  of  the  cord,  all  is  negligence  or  want  of  care.  But  among 
the  ancients,  it  was  an  act  that  had  its  rules,  nay  even  laws;  and  among  cer- 
tain people,  even  now,  much  precaution  is  exercised." 

Tliat  "the  ancients  never  employed  instruments  made  of  iron  to  cut  the  um- 
bilical cord;  for,"  adds  he  gravely,  "it  is  very  dangerous  in  tliis  operation,  to 
do  so  within  the  tropics.  For  if  we  apply  a  microscope  to  the  cut  portion  of  the 
cord,  we  shall  find  particles  of  the  metal  oxyded,  or  rusted;  and  these  are  more 
numerous  between  the  tropics,  tlian  in  other  climates.  These  particles  exert 
a  deleterious  effect  upon  the  wounded  cord,  which  in  hot  climates,  is  destruc- 
tive to  the  whole  economy  of  the  child." 

"It  was,"  continues  he,  "with  a  view  to  .avoid  these  dangers,  that  Moses 
ordered  circumcision  to  be  performed  with  a  sharp-edged  stone.  And  tlie  Jews 
in  all  countries,  witliout  understanding  tlie  reason  which  governed  their  law- 
giver, abide  with  great  ex.actness  to  his  precepts,  and  never  employ  Insti-uments 
made  of  iron  or  steel." — Medicine  Matemelle,  p.  6.  and  7. 

It  would  be  no  ways  difficult  to  perceive  too  much  refined  specul.ation  in 
these  opinions;  and  no  ways  difficult  to  account  for  Moses  employing  for  tliis 
purpose  a  stone  instead  of  iron ;  and  as  easy  to  prove,  tli.at  in  this  and  many  coun- 
tries, a  well-tempered  knife  is  employed  for  the  purposes  of  circumcision,  in- 
stead of  a  rough-edged  stone.  We  liave  frequently  seen  tliis  operation  perform- 
ed, and  it  has  always  been  with  a  knife  of  steel.  Nor  is  it  reasonable  to  sup- 
pose that  Moses  could  have  been  aware  of  oxyded  particles  being  left  by  the 
knife,  even  if  it  were  a  fact;  as  the  microscope  is  necessary  to  their  detection. 

j-  "No  harm  can  possibly  arise  from  the  application  of  two  ligatures,  and  we 
consider  it  the  safer  practice."  (Lond.  Med.  and  Phys.  Journ.  Aug.  p.  145.) 

I  regret  tliat  the  gentleman  who  honoured  this  woi-k  with  his  notice,  did  not 
state  wliy  two  ligatures  were  safer  than  one.  An  experience  of  more  than  forty 
years,  has  not  furnished  me  with  an  instance,  in  wliich  inconvenience  has  result- 
ed, wliere  only  one  has  been  applied. 


THE  UNASSISTED  DELIVERY  OV  THE  PLACENTA.  197 

and  the  expulsion  of  the  placenta — it  favours  the  contraction  of 
the  uterus,  by  the  vessels  of  the  placenta  emptying  themselves, 
and  thereby  diminishing  its  bulk;  this  reduction  proves  a  gene- 
ral and  grateful  stimulus  to  the  uterus,  and  promotes  its  contrac- 
tion; this  contraction  acts  upon  the  placenta,  so  as  to  disengage 
it  from  its  surface,  that  it  may  be  expelled,  soon  after  the  child  is 
born. 

Sect.  II.  —  The  Unassisted  Belivery  of  the  Placenta. 

556.  After  the  child  is  separated  from  the  mother,  it  is  to  be 
given  to  the  nurse,  and  removed  from  the  bed-side — the  next  duty 
is  to  deliver  the  placenta — but  before  this  is  attempted,  we  should 
first  ascertain  the  condition  of  the  uterus,  by  examining  it  through 
the  parietes  of  the  abdomen,  by  placing  a  hand  over  its  region. 
This  examination  will  discover  this  organ  in  one  of  two  condi- 
tions: namely,  contracted,  or  not  contracted.  If  the  first,  the 
placenta  may  be  delivered,  provided  it  be  loose  in  the  vagina,  by 
tightening  the  cord  with  the  left  hand,  and  tracing  it  with  the 
fore-finger  of  the  right  to  the  placenta,  which  is  to  be  hooked  with 
the  introduced  finger,  and  gently  drawn  by  the  cord  with  the 
other  hand,  until  it  pass  through  the  os  externum — we  should 
then  grasp  it  with  both  hands,  and  give  it  several  twirls,  to  twist 
the  membranes,  that  they  may  be  entirely  withdrawn  from -the 
uterus — the  advantages  of  this  proceeding  are,  Ave  prevent  a  ter- 
rible stench;  and  occasionally,  alarm;  for  we  have  known  them, 
when  about  to  escape  from  the  vagina  some  days  after  delivery, 
lo  excite  great  terror  in  the  patient  and  her  friends ;  by  their 
being  mistaken  for  a  falling  down  of  the  uterus. 

557.  When  the  placenta  is  delivered,  it  is  to  be  carefully  placed 
in  a  basin,  or  pot,  and  removed — the  abdomen  should  again  be 
examined;  should  the  uterus  be  well  contracted,  which  is  easily 
determined  by  its  hardness  and  size,  we  should  entertain  every 
reasonable  hope,  that  everything  is  going  on  so  far  well ;  but 
should  the  uterus  be  found  flaccid,  brisk  frictions  with  the  open 
hand,  with  the  occasional  grasping  pressure  of  the  fingers,  should 
be  instantly  made.  Should  these  be  successful,  the  uterus  vvill 
be  found  to  harden  gradually,  as  well  as  to  diminish  in  size  under 
the  hand.  At  this  moment,  perhaps,  there  may  be  a  sudden  dis- 
charge of  coagula  from  the  vagina,  accompanied  by  some  pain, 
which  very  fi-equcntly  alarms  the  inexperienced  practitioner,  and 


198  OF  AFTER-PAINS. 

renders  him  doubtful  of  the  propriety  of  the  plan  he  is  pursuing; 
but  so  far  from  being  alarmed  at  this  circumstance,  he  should  fe- 
licitate himself  upon  it ;  as  it  is  a  proof  that  the  uterus  is  con- 
tracting. These  frictions  should,  however,  be  continued  for  some 
time;  or  until  the  uterus  becomes  very  hard,  and  appears  to  be 
disposed  to  retire  within  the  pelvic  cavity. 

Sect.  III.— Of  Putting  to  Bed. 

558.  As  the  patient  is  usually  delivered  at  a  part  of  the  bed 
distant  from  where  she  is  to  be  permanently  placed,  the  removal 
from  one  to  the  other,  is  familiarly  called  "  putting  the  patient  to 
bed."  This  operation  consists  of  several  details,  w'hich  are  highly 
important  to  be  wxll  understood  by  the  young  practitioner; 
though  the  executive  part  does  not  strictly  belong  to  him.  "  Put- 
ting to  bed"  consists,  first,  in  the  entire  removal  of  all  the  wet 
things  that  may  be  about  the  woman,  and  substituting  dry  ones; 
second,  in  her  being  lifted  or  slid  into  the  place  where  she  is 
permanently  to  lie;  third,  in  the  application  of  a  bandage  over 
the  abdomen,  pinned  as  tightly  as  the  patient  can  bear  with 
comfort. 

559.  It  may  be  asked,  is  every  woman  to  be  put  to  bed  so  soon 
as  .she  may  be  delivered?  certainly  not;  the  "putting  to  bed," 
must  be  governed  by  the  following  circumstances:  first,  if  the 
patient  be  very  much  exhausted  by  the  severity  of  the  labour,  by 
a  previous  flooding,  or  any  other  circumstance  that  may  render 
her  feeble  or  faint,  she  must  not  be  removed  until  she  recover 
some  of  her  spent  strength,  should  this  require  even  several  hours; 
second,  should  the  patient,  from  her  exertions  during  labour,  or 
the  heat  of  the  weather,  be  in  a  perspiration,  she  should  not  be 
disturbed  juntil  this  has  gone  ofi'  entirely;  third,  should  there  be 
too  great  a  discharge  or  flooding,  the  patient  must  not  be  moved, 
until  this  is  much  diminished  or  stopped.  But  if  neither  of  these 
conditions  present  themselves,  it  is  best  to  direct  the  patient  to 
be  put  to  bed  immediately,  as  I  am  persuaded  she  will  bear  it 
better,  than  if  suffered  to  remain  any  time. 

Sect.  IV.  —  Of  ^fter-pams. 

5G0.  Almost  every  woman,  with  the  exception  perhaps  of  the 
first  child,  is  tormented  with  what  are  called  "after-pains,"  these 
pains  are  produced  by  the  renewal  of  the  alternate  contractions  of 


OF  AFTER-PAINS.  199 

the  uterus  in  consequence  of  coagula  forming  from  time  to  time, 
within  its  cavity,  and  now  being  foreign  bodies,  efforts  are  made 
by  the  uterus  to  expel  them.  These  coagula  are  formed  by  the 
blood  flowing  into  the  cavity  of  the  uterus  from  the  extremities 
of  the  vessels  exposed  by  the  separation  of  the  placenta — and  they 
will  form  in  proportion  as  the  uterus  may  be  more  or  less  disposed 
to  contract ;  therefore  it  is  found,  that  the  more  this  organ  is 
closed  by  virtue  of  its  tonic  power,  the  fewer  and  milder  will  be 
the  "after-pains:"  hence  these  pains  rarely  occur  with  the  first 
child,  as  the  tonic  power  of  the  uterus  is  then  more  perfect,  or  less 
exhausted.  There  is  a  circumstance  attending  these  pains,  which 
deserves  notice,  though  it  may  not  be  easily  explained;  which  is, 
their  almost  uniform  renewal,  upon  the  application  of  the  child  to 
the  breast,  though  they  may  have  been  suspended  even  for  hours; 
and  the  aggravation  of  them,  if  they  have  not  been  interrupted. 

561.  These  pains,  by  the  old  women,  are  considered  useful, 
because  they  are  almost  always  accompanied  by  the  discharge  of 
coagula,  which  they  say  must  come  away,  and  on  this  account 
they  oftentimes  refuse  to  give  anything  for  their  relief.  But 
this  doctrine,  were  it  strictly  acted  upon,  would  subject  the  patient 
to  most  unnecessary  tortures,  sometimes  for  many  days  together 
— I  have  ever  regarded  after-pains  as  an  evil  of  magnitude,  and 
always  endeavoured  to  prevent  them  as  quickly  as  possible — 
they  interrupt  sleep,  which  is  at  this  time  of  especial  importance 
to  the  exhausted  woman,  as  well  as  needlessly  excruciate  the 
body. 

562.  I  generally  prescribe  camphor  for  their  relief,  and  in  the 
following  form  : 

R.     Gum  Camph.  3j. 

Sr.  vin.  rect.  q.  s.  f.  pulv. — Adde 

Pulv.  G.  Arab.  3ij. 

Sacch.  alb.  3ij. 

Aq.  font,  ^vj— M. 
Of  this,  a  table-spoonful  is  given  every  hour  or  two,  or  oftener, 
until  the  pains  cease — or,  I  sometimes  give  ten  grains  of  this 
substance  finely  powdered,  every  hour  or  two,  mixed  in  a  little 
syrup  of  any  kind;  this  appears  to  answer  nearly  as  well  as  the 
julep  just  mentioned. 

563.  The  camphor,  in  two  or  three  instances,  has  disagreed 
with  the  patient,  though  it  relieved  the  pain.  In  these  cases,  it 
produced  most  distressing  feelings:  as  head-ache  and  delirium; 


200  OF  AFTER-PAINS. 

but  they  soon  disappeared  upon  desisting  from  it* — it  has  a  de- 
cided advantage  over  opium;  for  in  many  instances  it  can  be  given 
where  the  opium  is  altogether  improper,  either  from  the  state  of 
the  pulse,  or  idiosyncrasy  ;  besides,  it  more  certainly  gives  relief. 
I  think,  however,  that  the  relief  is  not  quite  so  permanent  as  that 
procured  by  opium ;  and  therefore,  we  are  sometimes  obliged  to  re- 
peat it  more  frequently.  Should  the  camphor  fail  to  give  relief, 
or  constitutional  peculiarity  render  it  improper,  vve  must  give  the 
opium;  provided,  there  be  no  circumstance  of  the  system,  as  fever, 
which  would  make  it  inadmissible.  I  have  in  a  few  instances 
been  obliged  to  let  blood,  from  the  high  action  of  the  arterial  sys- 
tem, before  I  could  venture  upon  the  use  of  opium;  but  these 
cases  are  rare,  though  of  high  consequence  to  be  well  understood 
in  practice.  I  have,  however,  given  the  camphor,  where  1  dared 
not  venture  upon  the  opium;  and  this  is  important  to  know,  as 
preparatory  bleeding  always  excites  alarm. 

564.  We  often  find  patients  who  cannot  use  opium  in  any  of 
its  common  forms,  in  consequence  of  its  disagreeable  after-ef- 
fects; such  as  severe  head-ache,  and  distressing  sickness  of  sto- 
mach.t  But  these  consequences  may  very  often  be  prevented  by 
mixing  the  laudanum  with  vinegar  instead  of  water;  or  using  the 
acetated  tincture  of  opium,  or  black  drop.  When  used,  it  should 
be  in  such  doses  as  will  quickly  make  an  impression  upon  the 
system— I  therefore  always  begin  with  a  dose  of  fifty  or  sixty 
drops,  and  repeat  it  every  half  hour  or  hour,  until  relief  is  pro- 
cured; if  the  black  drop  be  made  choice  of,  it  should  be  given  in 
half  the  quantities  of  the  laudanum.  If  this  plan  be  persisted  in 
for  a  short  time,  it  will  certainly  relieve  the  patient.  % 

*  In  one  case,  the  unpleasant  symptoms  were  so  excessive,  as  to  oblige  me 
to  give  .in  emetic  of  ipecacuanha.  As  soon  as  the  camphor  was  thrown  up, 
the  patient  was  relieved.  But  these  are  extremely  rare  cases;  and  were  I  to 
institute  a  comparison,  I  would  say,  that  opium  disagrees  five  tunes  as  often  as 
camphor. 

+  Dr.  Hare  has  pointed  out  a  method  of  freeing  opium  from  its  narcotine^ 
and  laudanum  is  now  prepared  from  the  residue,  with  the  great  advantage  of 
not  producing  any,  or  but  in  a  very  shght  degree,  the  distressing  effects  of  that 
made  in  the  common  way.  We  regai-d  tliis,  among  tlie  happiest  and  most  im- 
portant discoveries  of  modern  Chemistiy. 

4:  Until  the  «  denarcotised  laudanum,"  gets  into  general  use,  as  it  certainly 
will,  the  plan  recommended  in  the  text  may  be  pursued  with  advantage.  Dr. 
Physick  informs  me,  that  he  is  in  the  habit  of  using  a  few  grains  of  the  carbo- 
nate of  soda  or  potash,  with  the  same  good  effects. 


OP  AFTER-PAINS.  aOl 

565.  I  have  met  with  a  few  cases  of  a  very  distressing  kind  of 
after-pain,  which  I  have  not  seen  noticed  by  writers.  It  is  a 
most  severe  and  constant  pain  at  the  very  extremity  of  the  sacrum 
and  coccyx;  it  begins  the  instant  the  child  is  born;  and  con- 
tinues with  the  most  agonizing  severity,  until  overcome  by  the 
rapid  and  liberal  use  of  camphor  and  opium.  It  is  declared  by 
the  patient,  to  be  vastly  more  insupportable  than  the  pains  of 
labour;  for  it  is  as  intense,  as  unceasing, 

566.  The  first  case  of  this  kind  I  met  with,  occasioned  me  no 
little  anxiety  and  perplexity,  from  its  novelty  and  severity.  It 
was  the  case  of  a  young  lady  with  her  first  child — it  began  most 
severely,  the  instant  the  child  was  born;  and  its  intensity  was 
such  as  to  make  me  abandon  the  delivery  of  the  after  birth,  to 
attempt  the  relief  of  my  patient.  I  at  first  looked  upon  it  as  only 
a  protracted  after-pain,  which  I  had  not  expected  to  encounter 
with  a  first  child.  I  immediately  gave  a  large  dose  of  laudanum, 
and  repeated  it  in  fifteen  minutes — and  at  the  end  of  the  second 
quarter  of  an  hour,  as  there  was  no  abatement  of  the  sufiering,  I 
again  gave  the  laudanum — these  doses  procured  no  relief,  in  half 
an  hour  more;  though,  in  the  three  portions  exhibited,  more  than 
two  hundred  drops  of  this  medicine  were  given,  in  the  course  of 
half  an  hour.  I  was  obliged  now  to  suspend  the  repetition  of  the 
laudanum  from  a  fear  of  an  excess  in  its  exhibition;  but,  to  amuse 
the  patient,  I  gave  her  a  few  drops  at  a  time,  disguised  by  a  little 
of  the  compound  spirit  of  lavender,  until  an  hour  had  passed.  By 
this  time  the  patient  thought  herself  easier;  but  still  suffered  very 
severely — I  now  ventured  upon  another  full  dose  of  laudanum, 
and  sat  down  to  deliver  the  placenta:  this  was  readily  done,  and 
it  was  found  lying  loose  in  the  vagina;  but  its  expulsion  procured 
no  abatement  of  sufiering — in  a  word,  nearly  five  hundred  drops 
of  laudanum  were  administered,  before  complete  relief  was  ob- 
tained. After  she  became  easy,  she  had  no  subsequent  return  of 
this  pain ;  nor  did  she  suffer  in  the  least,  from  the  use  of  so  large 
a  quantity  of  laudanum,  in  so  short  a  period. 

567.  On  the  termination  of  her  next  labour,  as  she  had  most 
anxiously  and  fearfully  anticipated,  the  same  violent  distress 
assailed  her.  I  instantly  gave  her,  at  one  dose,  one  hundred  and 
twenty  drops  of  laudanum;  this  was  repeated  in  twenty  minutes 
— in  the  mean  time,  the  placenta  was  spontaneously  discharged. 
This  second  dose  afforded  no  relief;  and  I  was  then  induced  to 
administer  the  laudanum  at  short  intervals,  which,  as  before, 
26 


202  OF  AFTER-PAINS. 

eventually  overcame  the  pain — as  happened  on  the  former  occa- 
sion, she  suflered  no  return  of  this  pain  after  it  had  once  been 
subdued. 

56S.  On  her  third  confinement,  I  was  again  distressed  to  find 
a  recurrence  of  this  terrible  agony.  I  had  however,  from  my 
former  experience  in  her  case,  anticipated  this  event,  and  had  at 
hand  the  following  julep: 

1^         Gum  Camph.  3ii. 

Sp.  vin.  rect.  q.  s.  f.  pulv. — Adde 

Pulv.  G.  Arab.  3iii. 

Tinct.  opii  acetat.  3iiss. 

01.  Juniperi.  gut.  xx. 

Sacch.  alb.  q.  s. 

Aq.  font.  5vi, M. 

Of  this,  a  large  table-spoonful  was  given  about  fifteen  minutes 
before  I  expected  the  child  to  be  born,  by  way  of  making  some 
impression  before  the  pain  should  come  on.  The  child  was  born 
rather  within  the  period  I  had  calculated;  and,  as  on  the  two  for- 
mer occasions,  the  pain  commenced  the  instant  it  was  in  the 
world;  another  spoonful  of  the  julep  was  immediately  given, 
and  this  was  followed  by  another  in  fifteen  minutes  more,  which 
decidedly  abated  the  severity  of  the  pain;  and  I  had  the  satisfac- 
tion of  seeing  it  entirely  conquered,  in  an  hour  from  its  commence- 
ment; a  period  less  by  one  half  than  on  the  former  occasions. 
The  placenta  came  away  without  trouble,  as  it  had  always  done 
before.  I  thought  it  evident,  that  the  combination  of  camphor 
with  the  opium  was  highly  beneficial;  and,  perhaps,  they  were 
aided  by  the  oil  of  juniper,  which  I  had  frequently  found  very 
useful  in  controlling  after-pains.  On  her  fourthdelivery  she  was 
managed  precisely  as  above  related,  and  "with  the  same  happy 
eflects.  * 

569.  The  second  and  third  cases  which  fell  under  my  notice, 
were  treated  with  camphor  julep,  as  above  stated,  and  with 
the  same  happy  results.  Can  this  pain  be  considered  as  a  modi- 
fication of  after-pains?  I  am  disposed  to  think  not;  as  its  com- 
mencement is  too  sudden,  and  its  duration  too  uninterrupted; 
besides  after  this  pain  has  ceased,  the  part  no  longer  becomes  the 
seat  of  pain,  should  after-pains  follow.  That  strange  variations 
in  the  seat  of  after-pains  occasionally  take  place,  I  have  witness- 

*  This  lady  suffered  in  the  same  manner  with  her  fifth  and  sixth  cliildren. 


OP  AFTER-PAINS.  203 

ed;  but  in  all  the  Aberrations  I  have  observed,  the  change  of  seat 
did  not  alter  the  cliaracter  of  the  pains — for  they  were  all  of  the 
alternate  kind,  and  as  regular,  as  if  they  were  seated  in  the  uterus. 
One  of  the  most  remarkable  I  remember  to  have  met  with,  was 
where  the  after-pains  were  located  in  the  right  knee;  and  this 
peculiarity  in  seat,  obtained  with  every  child  this  lady  bore. 

570. 1  am  of  opinion,  however,  that  much  may  be  done  before 
the  labour  is  finished,  and  immediately  after,  to  abate  the  seve- 
rity, if  not  to  prevent  the  occurrence  of  "  after-pains."  During 
labour;  1st.  By  rupturing  the  membranes  whenever  the  mouth 
of  the  uterus  is  sufficiently  dilated  to  permit  the  head  to  pass,  that 
the  tonic  contraction,  may  immediately  ensue;  by  this  the  follow- 
ing advantages  result  as  regards  the  prevention  of  "after-pains:'* 
by  the  absence  of  the  waters,  the  uterus  is  reduced  in  size,  in  pro- 
portion to  the  quantity  discharged;  this  gives  greater  strength  to 
this  organ,  and  enables  it  to  contract  with  more  force;  and  con- 
sequently, will  more  certainly  diminish  the  size  of  the  vessels  ex- 
posed by  the  separation  of  the  placenta;  as  these,  by  pouring  out 
blood,  give  rise  to  these  "after-pains;"  (193)  again,  it  prevents 
the  uterus  from  being  too  suddenly  emptied;  and  thus  inducing  a 
state  of  atony  in  it — for  it  must  be  remembered,  that  "after-pains," 
are  never  more  certain,  nor  ever  more  severe,  than  after  a  very 
quick  labour.  2d.  By  permitting  the  uterus  to  finish  the  labour 
after  the  head  is  born ;  in  doing  this,  we  have  an  assurance  that 
the  tonic  contraction  has  regularly  followed;  as  the  uterus  be- 
comes more  and  more  empty ;  for,  were  this  not  the  case,  the  al- 
ternate contractions  would  be  feeble  and  transitory,  as  always 
happens,  when  the  shoulders  are  about  to  be  hurried  through  the 
external  parts  and  the  uterus  too  suddenly  emptied;  in  this  case 
the  tonic  contraction  of  course  is  imperfect — consequently,  the 
vessels  exposed  by  the  separation,  and  departure  of  the  placenta, 
are  not  pressed  upon  by  this  power;  and  consequently  blood  is 
freely  poured  into  the  cavity  of  the  uterus,  where  it  coagulates, 
and  obliges  the  uterus  to  throw  it  off  by  repeated  contractions. 
3d.  After  the  delivery  of  the.child,  we  may  do  much  by  not  at- 
tempting the  delivery  of  the  placenta  until  we  have  ensured  the 
tonic  contraction  of  the  uterus,  by  frictions  as  before  recommended, 
over  the  hypogastric  region;  and  after  its  expulsion  to  repeat  them, 
until  the  uterus  seems  to  retire  considerably  within  the  pelvic 
cavity.  Burton's  success,  (though  I  should  be  but  little  disposed 
to  follow  his  practice,)  in  preventing  ''after-pains"  by  the  intro- 


204  or  AFTER-PAINS. 

duction  of  his  hand  to  the  fundus  of  the  uterus,  and  kept  there 
until  he  found  this  organ  contracting  upon  it,  depended  precisely 
upon  the  principle  I  have  been  endeavouring  to  establish;  namely, 
promoting  as  quickly  and  as  certainly  as  possible,  the  tonic  con- 
traction of  the  uterus. 

571.  It  must,  however,  be  admitted,  that  neither  camphor  nor 
opium  is  always  successful  in  calming  these  distressing  contrac- 
tions of  the  uterus;  they  sometimes  persevere  with  great  obsti- 
nacy, even  after  the  faithful  trial  of  both  these  remedies;  while 
in  other  cases,  no  form  of  opium  can  be  made  to  suit  the  peculiar 
idiosyncrasy  of  the  patient,  and  to  some  the  camphor  is  altogether 
disgusting.  In  such  cases  it  may  be  highly  useful  to  exhibit  the 
hydrocyanic  acid,  as  recommended  by  Dr.  Von  dem  Busch,  of 
Bremen. 

572.  As  this  is  a  new  remedy  in  spasms  of  the  uterus;  and  as 
its  effects  were  highly  satisfactory  to  Dr.  Von  dem  Busch,  I  will 
subjoin  the  two  cases  related  by  him  in  Hufeland's  Journal  for 
September,  1826. 

573.  Case  I.  "Madame  N.  aged  thirty-three  years,  was  safely 
delivered  in  the  morning  of  the  14th  May,  1821.  A  short  time 
however  after  she  was  put  to  bed,  she  was  attacked  with  a  violent 
vomiting,  and  severe  after-pains.  She  was  visited  an  hour  after 
by  her  physician ;  she  had  by  this  time  vomited  five  times,  a  green, 
bitter  substance  like  bile;  the  pulse  was  full  and  hard;  the  abdo- 
men tense,  and  tender  to  the  touch;  the  skin  hot,  but  the  face  not 
flushed  ;  tongue  clean,  and  thirst  great.  The  patient  complained 
of  pains  in  the  uterus;  and  when  they  became  very  violent,  they 
excited  nausea  and  vomiting.  The  lochia  was  very  sparing.  Three 
drops  of  the  hydrocyanic  acid  mixed  in  an  ounce  and  an  half  of 
syrup  was  given  by  tea-spoonful  every  hour.  In  the  evening  the 
pulse  had  softened,  the  patient  had  vomited  but  twice;  the  abdo- 
men still  painful  to  the  touch;  nausea  continued,  but  the  after- 
pains  were  much  less  frequent.  The  lochia  returned  in  abundance 
during  the  night  of  the  14th,  and  the  day  of  the  15th,  after  hav- 
ing repeated  during  the  day  the  mixture;  it  was  now  given  but 
once  in  three  hours,  as  the  pains  had  entirely  disappeared.  This 
lady  lias  been  twice  delivered  since;  in  both  she  again  suffered 
with  after-pains,  but  not  accompanied  by  vomiting;  in  both  cases 
she  was  relieved  by  the  same  remedy." 

574.  Case  II.  "Madame  S.  a  well-made  robust  woman,  twenty- 
eight  years  of  age,  was  always  delivered  safely,  and  without  any 


THE  REGIMEN  DURING  THE  MONTH,  &C.  205 

thing  unpleasant  following  her  labours.  But  in  her  fourth  delivery, 
the  after-pains  were  so  violent  as  to  cause  convulsions.  The  lochia 
were  nearly  suppressed ;  the  pulse  full  and  hard ;  the  tongue  clean, 
and  the  skin  hot ;  pressure  on  the  hypogastrium  increased  the 
pains.  Four  drops  of  the  hydrocyanic  acid  in  two  ounces  of 
syrup  were  ordered ;  of  this  a  tea-spoonful  was  given  every  hour 
and  a  half.  The  pains  subsided  presently,  and  by  the  time  the 
mixture  was  finished,  they  had  ceased  entirely ;  in  the  mean  time 
the  lochia  returned  to  their  healthy  condition.'^* 

Sect.  V. — The  Regimen  During  the  Month,  S,'C. 

575.  There  is  no  vulgar  error  more  replete  with  mischief,  than 
that  which  supposes  the  woman  to  be  in  a  state  of  great  debility 
after  delivery,  and  to  require  the  most  nourishing,  and  the  most 
stimulating  things  to  overcome  it — hence  the  destructive  use  of 
ardent  spirits,  wine,  cordials,  spices,  animal  food,  and  broths,  &c. 
&c  during  the  whole  period  of  confinement.  We  cannot  too  de- 
cidedly set  our  faces  against  such  practices;  and  with  a  hope  of 
preventing  them,  we  should  give  to  the  nurse  the  most  explicit 
directions,  as  well  as  the  most  positive  injunctions,  with  regard  to 
the  regimen  of  the  patient,  before  we  leave  the  room;  and  we 
should  see  as  far  as  may  be  in  our  power,  that  our  instructions  are 
carried  rigidly  into  execution. 

576.  Should  we  have  reason  to  suspect,  or  have  positive  evi- 
dence that  they  have  been  departed  from,  we  should  at  once,  with- 
out regard  to  the  nurse's  experience  or  respectability,  tax  her  with 
this  disobedience — for  it  must  be  recollected  that  the  whole  re- 
sponsibility lies  with  the  physician;  and  if  he  do  not  support  his 
instructions  with  proper  firmness  and  dignity,  and  see  them  cor- 
rectly acted  upon;  if  he  pass  in  silence  the  improper  conduct  of 
the  nurse,  he  will  constantly  and  evermore  have  his  directions 
infringed,  and  his  skill  and  experience,  be  them  what  they  may, 
rendered  nugatory. 

577.  But  to  return  to  the  regimen  proper  in  the  month;  I  de- 
sire that  the  patient  ma7/  not  have  animal  food,  or  broth  from 
any  animal  substance;  that  she  may  take  neither  distilled  nor 
fermented  liquor;  nor  any  stimulating  tea  "to  dispel  wind,"  or 
"to  allay  after-pains,"  or  to  "promote  the  lochia."  I  direct 
she  should  have  gruel  of  oat  meal,  tapioca,   sago,  panada,  mush 

*  Revue  Medicale,  &.c.  for  April,  1827. 


20G  THE  REGIMEN  DURING  THE  MONTH. 

and  milk,  rice  and  milk,  tea,  coffee,  or  very  thin  chocolate. 
I  permit  to  be  seasoned  with  sugar,  a  little  nutmeg,  or  lemon 
juice,  any  of  the  articles  above  enumerated,  in  which  it  would 
be  proper  to  use  them.  I  permit  the  use  of  toast-water,  barley- 
water,  molasses  and  water,  or  balm-tea  as  common  drinks;  or 
what  is  very  often  extremely  grateful  to  them,  apple-water — that 
is,  a  roasted  apple  or  more,  well  beaten  with  water,  and  af- 
terwards strained.  This  diet  is  to  be  observed  strictly  until  after 
the  fifth  day;  or  until  the  milk  has  been  freely  secreted,  and  is 
easily  extracted — after  this  time,  all  things  being  right,  she  may 
be  allowed  the  soft  ends  of  four  or  five  oysters,  or  a  poached 
egg,  a  little  chicken-water,  beef-tea,  or  vegetable  soup  may  fol- 
low, until  about  the  tenth  day:  then,  (nothing  forbidding,)  she 
may  indulge  in  a  little  ale,  or  porter  and  water  at  her  dinner ; 
and  if  requested,  a  table-spoonful  of  white  wine  may  be  added  to 
the  gruel,  &c.  This  plan  I  persevere  in  until  after  the  fifteenth 
day;  at  which  time  she  generally  may  take  some  animal  sub- 
stance, such  as  broiled  or  boiled  chickens ;  birds  of  almost  any 
kind  ;  a  piece  of  beef-steak,  mutton-chop,  &:c. 

578.  The  child  should  be  put  to  the  breast,  as  soon  as  the 
mother  is  well-rested  from  the  fatigue  of  labour;  this  is  an  im- 
portant direction ;  and  should  not,  without  very  strong  reasons, 
be  neglected:  the  advantages  of  this  early  application  of  the  child 
to  the  breast,  are;  first,  the  child  keeps  the  faculty,  (if  we  may  so 
term  it,)  of  sucking,  with  which  it  is  born;  for  if  this  direction 
be  not  attended  to  for  several  days,  because,  as  they  say,  the 
mother  has  no  milk,  it  will  lose  this  faculty,  and  much  trouble 
will  be  given  to  recall  it — I  have  witnessed  this  consequence  but 
too  often;  second,  the  child's  mouth  will  by  its  gentle  action 
upon  the  nipple,  gradually  stretch  it,  and  accustom  it  to  exten- 
sion, before  the  breasts  become  tender,  and  swelled  with  milk; 
third,  by  the  nipple  being  stimulated  by  the  child's  sucking,  an 
earlier  secretion  of  milk  takes  place;  fourth,  the  milk  will  be 
drawn  off,  nearly  as  fast  as  formed;  which  will  prevent  the  pain 
so  constantly  arising  from  its  accumulation,  as  well  as  the  swell- 
ing, which  is  almost  sure  to  follow  its  formation.  This  swell- 
ing, if  it  take  place,  shortens  the  nipple,  and  renders  the  extrac- 
tion of  the  milk  more  difficult;  this  increases  the  efforts  of  the 
child,  by  which  means  the  external  covering  of  this  important 
little  organ  becomes  irritated,  and  sore,  to  the  great  misery  of 
the  mother,  and  serious  injury  to  the  child;  fifth,  the  early  se- 


THE  REGIMEN  DURING  THE  MONTH.  207 

creted  milk  possesses  a  purgative  quality,  by  which  the  infant 
profits,  by  its  assisting  in  carrying  ofi' the  meconium.* 

579.  It  should  be  directed,  that  the  room  be  constantly  venti- 
lated; the  curtains,  if  there  be  any,  should  always  be  open;  and 
where  we  can  command,  we  should  forbid  them  altogether,  in 
warm  weather.  They  should  never  be  drawn,  because  the 
woman  sleeps,  or  with  a  view  to  protect  her  from  a  draught  of 
air;  for  the  woman  can  sleep  without  closed  curtains;  and  can 
by  other  contrivances  be  protected  against  a  current  of  air.  She 
should  have  a  plentiful  change  of  cloths,  that  the  lochia  may  not 
become  offensive;  and,  after  the  third  day,  she  should  be  per- 
mitted to  wash  the  parts  with  warm  water,  two  or  three  times  a 
day — this  last  permission  is  a  great  comfort  to  a  delicate  woman; 
and  should  not  under  frivolous  pretences,  be  denied  her. 

580.  On  the  third  day  if  the  bowels  have  not  been  previously 
opened,  the  woman  should  take  some  mild  purgative;  castor  oil 
is  the  best;  but  where  this  is  disgusting,  or  should  disagree,  the 
calcined  magnesia,  the  syrup  of  rhubarb,  or  a  little  senna  tea, 
will  answer  extremely  well.  Should  the  "  after-pains"  be  very 
obstinate,  and  not  yield  to  the  common  remedies,  the  castor  oil 
will  be  found  to  be  the  most  useful  purgative;  and  has  this  very 
decided  advantage  over  every  other,  perhaps,  that,  in  cases  of 
great  pain,  laudanum  can  be  administered,  if  it  be  judged  proper 
to  exhibit  it,  without  interrupting  the  operation  of  the  oil,  though 
it  may  retard  it  a  little.  A  strict  attention  should  also  be  paid 
to  the  state  of  the  bladder — we  should  never  forget  to  inquire 
whether  the  patient  has  passed  water;  if  she  has  not,  we  should 
immediately  order  such  remedies  as  are  best  calculated  to  remove 
the  difficulty— the  most  certain  is  sp.  nitri.  dul.  (sp.  »ther. 
nit.)  in  tea-spoonful  doses,  repeated  every  two  hours,  until  relief 
be  obtained;  for,  if  this  fail,  it  is  more  than  probable  no  other 
diuretic  will  succeed;  we  are  then  under  the  necessity  of  em- 

*  We  are  persuaded,  that  the  "milk  fever,"  as  it  is  called,  is  nearly  altog-e- 
ther  of  artificial  origin,  and  can  almost  constantly  be  prevented.  We  have  been 
always  attentive  to  tliis  subject,  and  an  ample  experience  leads  us  irresistibly  to 
this  conclusion.  In  a  practice  of  more  than  forty  years,  we  have  witnessed  but 
two  instances  of  inevitable  '« milk  fever,"  In  both  of  these,  every  pains  were 
taken  to  prevent  the  formation  of  this  fever,  but  in  neither  did  a  severe  anti- 
phlogistic treatment  prevent  it— in  botl\  of  these  cases,  the  patients  were  ex- 
tremely prone  to  fever  from  very  slight  causes.  We  therefore  cannot  agree 
with  Professor  Dubois,  that  the  "  milk  fever"  is  a  legitimate  traumatic  fever 
occasioned  by  the  separation  of  the  placenta  from  tlie  uterus. 


208  THE  REGIMEN  DURING  THE  MONTH. 

ploying  the  catheter:  nor  should  we  delay  its  employment  too 
long.  I  have  seen  much  misery,  and  perhaps  danger,  in  per- 
mitting the  bladder  to  be  too  long  distended. 

581.  The  following  is  the  mode  of  using  this  instrument — the 
patient  must  be  placed  at  the  side  of  the  bed;  the  bed  should  be 
protected  by  a  folded  blanket  being  placed  under  her.  The 
finger  should  be  lubricated  with  a  little  sweet  oil  or  lard,  and  the 
hand  introduced  under  the  bed-clothes,  so  as  not  to  occasion  the 
smallest  exposure — the  patient's  knees  must  be  drawn  up,  and 
the  labia  separated  by  the  points  of  the  fingers — search  for  the 
inferior  edge  of  the  symphysis  pubis  under  which  the  urethra  im- 
mediately runs — press  this  part  gently  with  the  point  of  the  fin- 
ger, and  the  meatus  urinarius  will  be  for  the  most  part,  readily 
discovered — when  found,  keep  the  extremity  of  the  finger  upon 
it;  then,  with  the  other  hand  guide  the  catheter  along  it  until  it 
reach  the  orifice,  and  is  inserted  into  it;  press  it  gently  back- 
wards and  upwards,  until  it  enter  the  bladder;  and  prevent  the 
immediate  issue  of  urine,  by  placing  a  finger  upon  its  external  ex- 
tremity until  the  vessel  is  handed,  which  is  intended  to  receive  it 

this  is  to  be  so  placed,  as  to  prevent  the  escape  of  the  urine 

upon  the  bed — when  all  the  water  is  discharged  the  instrument 
must  be  withdrawn.  This  operation  must  be  repeated  until  the 
bladder  regains  its  powers,  and  is  capable  of  discharging  its  con- 
tents  it  sometimes  becomes  necessary  to  do  this  twice  or  thrice 

a  day;  but  in  general  once  will  do.* 

•  "If  it  were  our  only  purpose,  in  such  cases,  to  prevent  the  woman  from 
suffering'  pain  from  the  suppression  of  urine,  it  is  true  that  the  use  of  the  ca- 
theter once  a  day  'will  generally  do.'  But  we  have  a  much  more  important 
objectin  view,— to  prevent  the  natural  power  of  the  bladder  from  being  so  far 
weakened  by  over  distention,  that  a  very  considerable  time  may  elapse  before 
tlie  patient  is  able  to  pass  her  urine.  We  have  known  the  use  of  the  catheter 
necessary  for  many  weeks,  in  consequence  of  the  contractile  power  of  the  blad- 
der having  been  lost,  from  the  water  not  having  at  first  been  drawn  off  more  than 
once  in  twenty-four  houi-s.  We  differ  then  from  our  author,  upon  this  pomt. 
The  introduction  of  the  catheter  once  a  day,  ought  never  to  be  considered 
sufficient."     (Lo7id.  Med.  and  Phys.  Journ.  Aug.  1825,  p.  148.) 

The  reviewer  says  that  he  and  I  differ  upon  the  subject  of  the  catheter — but 
we  certainly  do  not :  on  the  contrary,  we  perfectly  agree.  My  practice  ever  has 
been,  to  draw  off  the  urine,  whenever  distention  was  evident;  did  this  require 
three  or  even  four  introductions  of  the  catheter,  in  twenty -four  hours.  But 
more  cases  have  occurred,  where  once  a  day  was  sufficient,  than  where  a  more 
frequent  use  of  tlie  catheter  was  necessary;  nor  have  we  ever  witnessed  a  case, 
which  required  a  continuance  of  this  operation  beyond  a  week.  In  Europe, 
this  necessity  is  both  more  frequent,  and  much  more  urgent ;  owing  to  the 
much  greater  frequency  of  contracted  pelves,  or  tedious  labours. 


OP  THE  LOCHIA.  209 

Sect.  VI. — Of  the  Lochia. 

582.  The  discharges  which  take  place  from  the  uterus  after 
delivery,  arc  called  the  "lochia" — they  proceed  from  the  extre- 
mities of  the  vessels  exposed  by  the  separation  of  the  placenta; 
and  will  of  course  be  in  proportion  to  the  extent  of  surface  this 
mass  may  have  occupied  in  the  uterus;  the  number  and  size 
of  the  vessels  concerned;  and  the  degree  of  contraction  the 
uterus  may  exert.  Should  the  tonic  contraction  of  the  uterus  be 
imperfectly  performed,  an  hc-p.morrhage  will  be  the  consequence; 
but  when  more  perfectly  contracted,  the  discharge  will  not 
amount  to  a  flooding;  but  would  yield  the  lochia.  Much  con- 
sequence is  attached  to  these  discharges;  the  good  old  gossips  of 
almost  every  country  are  of  opinion  that  the  freer  they  are 
produced,  the  better;  and  are  always  better  pleased  with  a  super- 
abundant, than  with  a  sparing  quantity — it  is  proper  therefore, 
before  we  proceed  farther,  that  wc  determine  the  real  nature  of 
this  evacuation. 

583.  As  the  uterus  never  contracts  with  so  much  force  imme- 
diately after  delivery,  as  to  stop  the  mouths  of  all  the  exposed 
vessels,  a  quantity  of  blood  must  necessarily  proceed  from  the 
extremities  of  such  as  are  open  ;  and  this  quantity  will  be  in  pro- 
portion to  their  capacities,  though  perhaps  these  vessels  are  now 
much  reduced  in  size;  while  on  the  other  hand,  the  quantity  dis- 
charged, will  be  constantly  diminishing  in  the  exact  ratio  of  re- 
duction; it  must  therefore  follow,  there  is  no  definite  quantity  to 
be  evacuated,  but  will  entirely  depend  upon  the  contingency,  of 
the  more  or  less  perfect  condition  of  the  tonic  power  of  the  ute- 
rus. This  being  true,  it  must  also  follow,  that  the  quantity  dis- 
charged will  differ  in  each  individual,  and  in  the  same  individual 
at  each  particular  labour;  consequently,  there  can  be  no  rule 
upon  the  subject.  The  absolute  use  of  this  evacuation  appears  to 
be,  to  give  the  uterine  vessels  an  opportunity  to  contract,  by  gra- 
dually relieving  themselves  of  the  engorgement  to  which  they 
have  long  been  subject  from  pregnancy,  by  pouring  a  part  of 
their  contents  into  the  cavity  of  the  uterus;  and  that,  so  soon  as 
this  engorgement  is  relieved,  all  the  purposes  of  the  evacuation 
are  answered:  for  the  extremities  of  the  vessels,  which  open  into 
the  cavity  of  the  uterus,  cannot  return  the  blood  they  contain 
into  the  circulation,  as  their  anastomoses  are  destroyed,  by  their 

27 


210  LOCHIA,  EXCESSIVE. 

terminations  being  opened;  they  therefore  part  with  it,  and  thus 
form  the  lochia;  and  they  will  do  this,  until  the  tonic  contraction 
is  so  perfect,  as  to  shut  up  their  exposed  extremities — therefore, 
as  a  discharge,  this  evacuation  is  of  no  farther  use,  than  to  relieve 
the  vessels  of  the  uterus,  and  thus  indirectly  promote  its  contrac- 
tion— it  may  however,  injure  by  its  excess,  because,  it  may  pro- 
duce weakness;  but  cannot  injure  by  its  scantiness,  when  that  is 
the  effect  of  contraction,  since  this  is  an  evidence  of  the  most 
healthy  condition  of  the  uterus. 

a. — Lochia,  Excessive. 

584.  As  this  discharge  sometimes  injures  by  its  excess,  and  as 
that  excess  must  necessarily  result  from  a  want  of  due  contraction 
in  the  uterus,  it  follows  as  a  consequence,  that  we  always  render 
an  important  service,  when  we  can  increase  the  tonic  powers  of 
the  uterus,  and  thereby  diminish  the  quantity  of  the  lochia.  I 
have  for  many  years  acted  upon  this  principle,  and  have  great 
reason  to  be  satisfied  with  it.  It  is  very  unusual  in  my  practice, 
to  see  the  lochia  too  abundant;  on  the  contrary,  very  little  of  this 
discharge  is  to  be  seen  after  the  fifth  day,  and  sometimes  it  is  over 
sooner.  I  do  not,  however,  say,  that,  in  the  cases  just  alluded  to, 
there  is  an  entire  stoppage  of  the  discharge;  but  that  there  is  a 
very  great  abatement  of  it,  both  as  regards  quantity  and  intensity 
of  colour. 

585.  The  lochia,  however,  from  various  causes,  will  continue 
for  a  great  length  of  time,  nay,  during  the  month,  or  even  longer, 
to  the  injury  of  the  patient;  in  such  cases,  I  have  made  it  a  rule, 
to  interfere  whenever  it  has  continued  with  any  force  beyond  the 
tenth  day.  I  have  found  this  discharge  sometimes  kept  up  by  a 
febrile  condition  of  the  system,  occasioned  perhaps  by  an  impro- 
per consideration  of  the  case  by  the  friends  of  the  patient,  who 
could  not  imagine  that  any  other  cause  than  debility  produced 
the  discharge  in  question ;  accordingly,  wine,  bark,  and  cordials 
were  given,  with  a  view  to  arrest  it,  and  thus  perpetuated  the 
evil  they  intended  to  cure.  In  such  cases  there  are  pretty  regu- 
lar febrile  paroxysms,  especially  towards  evening;  a  quick  full 
pulse,  with  considerable  heat  of  skin — the  tongue  furred,  the 
bowels  oftentimes  much  confined;  a  feeble  state  of  stomach,  or  a 
whimsical  appetite ;  the  sleep  disturbed  and  unrefreshing;  pain 
in  the  back,  and  an  occasional  discharge  of  coagula.     In  treating 


LOCHIA,  EXCESSIVE.  211 

this  case  we  shall  have  much  prejudice  to  overcome — for  that 
fatal  term  ^^  clebilifij,^'  which  has  slain  its  thousands,  and  its  tens 
of  thousands,  is  always  employed  against  us;  "the  patient  is  so 
weak,  she  wants  something  to  strengthen  her,"  is  the  unceasing 
cry  of  friends  upon  such  occasions;  and,  though  they  will  reluc- 
tantly suhmit  to  your  directions,  they  will  rarely  coincide  with 
you  as  to  their  propriety.  We  must  not,  however,  give  up  prin- 
ciples, to  satisfy  the  crude  notions  of  friends,  upon  a  point  so  im- 
portant to  the  welfare  of  the  patient;  we  must  prescribe  agreea- 
bly to  the  opinion  we  have  formed  of  the  nature  of  the  case,  after 
a  due  consideration  of  the  symptoms,  and  condition  of  the  vascu- 
1  ar  system. 

586.  In  cases  like  these,  wc  cannot  expect  to  abate  the  dis- 
charge, until  we  shall  have  subdued  the  febrile  condition  of  the 
system;  we  are,  therefore,  to  begin  by  taking  a  few  ounces  of 
blood,  and  opening  the  bowels  freely,  with  any  of  the  neutral 
salts,  either  alone  or  combined  with  magnesia;  by  confining  the 
patient  strictly  to  a  vegetable  or  mild  diet,  and  the  entire  pro- 
scription of  wine  or  any  other  liquor,  and  all  stimulating  teas, 
such  as  chamomile,  centaury,  or  mint.  By  forbidding  all  exer- 
cise, or  even  sitting  up  in  severe  cases;  by  placing  the  patient 
upon  a  mattrass,  instead  of  a  feather  bed;  by  ordering  the  parts 
to  be  bathed  with  cool  water,  three  or  four  times  a  day.  After 
having  bled  and  purged  as  just  suggested,  we  may  give  from  a 
grain  and  a  half  to  two  grains  of  the  acetate  of  lead,  every  three 
or  four  hours.  The  following  is  the  formula  I  generally  employ 
for  such  purposes: — 

R.          Sacch.  Saturn.  3ij. 
Gum  opii.  gr.  vi. 
Conserv.  Rosar.  q.  s. 

M.  f.  pil.  xxiv. 

587.  During  the  exhibition  of  the  pills,  the  state  of  the  bowels 
should  be  regarded;  and  should  the  febrile  condition  not  be  sub- 
dued by  the  evacuations  already  employed,  we  should  again  have 
recourse  to  the  lancet.  It  will  rarely  happen  that  this  state  of 
circulation  will  not  yield  to  this  plan;  indeed,  the  very  omission 
of  the  improper  articles  which  were  before  employed,  will  very 
much  aid  us  in  our  endeavours.  After  the  system  is  freed  from 
fever,  we  shall  find  advantage  in  the  employment  of  some  gentle 
tonic;  the  elixir  vitriol,  in  doses  of  fifteen  or  twenty  drops,  three 
or  four  times  a  day,  in  strong  red-rose-leaf  tea,  properly  sweet- 


212  LOCHIA,  EXCESSIVE. 

ened,  is  a  very  useful,  as  well  as  grateful  remedy.*  It  must  be 
observed,  the  acetate  of  lead  may  be  suspended,  if  it  does  not  con- 
siderably check  the  discharge  in  the  course  of  five  or  six  days; 
and  should  always  be  intermitted  when  the  vitriolic  acid  is  given. 
Should  the  complaint  not  yield  to  this  plan  in  a  reasonable  time, 
I  have  seen  much  advantage  from  injections  per  vaginam,  of  the 
acetate  of  lead  and  water,  a  little  warmed,  and  thrown  up,  three 
or  four  times  a  day;  this  should  be  made  so  as  to  have  ten  grains 
of  the  acetate  to  an  ounce  of  water. 

58S.  At  other  times,  the  system  seems  to  be  rather  prostrated 
by  the  profusion,  or  the  long  continuance  of  the  discharge:  when 
this  is  the  case,  the  elix.  vitriol.,  as  above  directed,  should  be 
given  freely;  the  tincture  or  extract  of  rathana  will  also  be  found 
highly  useful,  as  will  sometimes  the  alum  whey:  the  parts  should 
be  bathed  as  just  directed:  the  patient  should  be  kept  quiet,  as 
above  suggested;  and  the  injections  be  had  immediate  recourse 
to;  this  plan  will  generally  prove  quickly  serviceable. 

589.  There  is  another  condition  of  the  lochia,  which  is  not  only 
very  troublesome,  but  from  its  offensive  smell  extremely  loath- 
some; this  is  where  the  coloured  discharge  has  disappeared,  but 
is  succeeded  by  a  profuse  watery  one,  of  a  greenish  colour;  and 
from  this  circumstance  is  called  by  the  old  women  the  "  Green 
water;"  it  is  frequently  so  acrid  as  to  excoriate  the  parts  over 
which  it  flows;  and  always  extremely  offensive  in  smell.  The 
woman  is  almost  always  much  debilitated  by  this  noisome  evacu- 
ation ;  and,  in  some  few  cases,  I  have  seen  a  kind  of  hectic  dispo- 
sition supervene. 

590.  The  system  almost  always  in  these  cases  requires  the  use 
of  tonics — the  decoction  of  bark  and  the  vitriol,  should  be  freely 
given;  and  the  patient  allowed  a  generous  diet,  with  either  ale 
or  porter,  in  moderate  quantities  at  dinner.  The  parts  should  be 
frequently  bathed  with  lukewarm  water;  and  injections  of  strong 
chamomile  tea,  in  which  a  piece  of  quick-lime  has  been  slacked  and 
permitted  to  settle,  should  be  used  per  vaginam,  four  or  five  times 
a  day — these  injections,  like  all  others  I  have  directed  for  the 
vagina,  should  be  a  little  warmed.  This  complaint,  as  far  as  I  have 
observed,  has  always  yielded  to  this  plan  of  treatment.    A  chlo- 

*  A  pint  of  boiling  water  is  to  be  poured  on  an  half  ounce  of  red  rose  leaves, 
and  allowed  to  stand;  strain,  as  wanted,- when  cold — sweeten  to  taste,  and  g-ive 
a  wine-glassful,  with  or  without  the  elixir  vitriol  as  may  be  judged  most 
proper.    If  used  without  the  vitriol,  it  may  be  given  every  two  hours. 


OF  WASHING  THE  CHILD.  213 

ruret  of  lime  or  soda  is  also  highly  useful,  and  may  be  used  per 
vagi  nam  three  or  four  times  a-day. 

591.  It  may  be  thought  incumbent  on  me  to  say  something,  oa 
that  condition  of  the  lochia,  where  this  discharge  is  too  sparing — 
but  I  have  already  said,  I  looJc  upon  this  as  a  favourable  sign  in 
the  ordinary  course  of  things;  when  it  exists  as  a  symptom  of 
another  complaint,  that  complaint  must  alone  be  considered. 

Sect.  VII. — Of  the  Mtentions  necessary  to  the  Child. 

592.  Hitherto  we  have  been  considering  the  attentions  due  to 
the  mother,  together  with  some  of  the  most  common  complaints 
attendant  upon  delivery:  I  shall  now  say  a  few  words  upon  the 
demands  of  the  child.  Under  this  head,  I  shall  first  direct  its 
washing;  2d,  dressing  of  its  navel;  3d,  the  medicines  proper  to 
purge  oflf  the  meconium;  4th,  its  food. 

a.  —  Of  JVashing  the  Child. 

593.  The  child's  body,  when  first  born,  is  almost  always  co- 
vered with  a  tenacious  unctuous  substance,  which  is  rather  trou- 
blesome to  remove.  It  has  been  analyzed  by  Vauquelin  and 
Buniva,  and  found  most  to  resemble  fat — they  have  not  disco- 
vered anything  which  readily  unites  with  it.  It  is,  however,  as- 
certained, that  hog's  lard  answers  better  than  anything  else  that 
we  know  of  to  detach  this  substance  from  the  skin.  When  the 
lard  has  become  well  incorporated  with  this  coating,  it  can  be  re- 
moved by  strong  warm  soap-suds,  and  a  piece  of  flannel,  or  sponge. 
It  should  be  carefully  taken  off  at  the  first  washing,  as  it  some- 
times encrusts,  and  excoriates  the  skin,  when  this  is  neglected. 
The  child,  during  this  process,  should  not  be  unnecessarily  ex- 
posed— if  it  be  cold  weather,  it  should  always  be  washed  near  the 
fire ;  and  should  be  carefully  dried  after  the  washing.  Many 
nurses  have  a  preposterous,  and,  as  I  believe,  an  injurious  practice 
of  using  brandy  or  some  other  liquor,  when  they  wash  the  child; 
and  especially  when  they  wash  the  head — this  practice  should  be 
forbidden ;  as  I  am  persuaded  that  it  has  oftentimes  been  very  in- 
jurious to  the  infant.  After  washing,  the  next  thing  to  be  attend- 
ed to  is, 

b. — The  Dressing  of  the  Navel. 

594.  Much  ceremony  was  formerly  observed  in  the  perform- 
ance of  this  office ;  but  it  has  now  become  a  process  of  great  oim- 


214  PURGING  OFF  THE  MECONIUM.     • 

plicity,  among  the  more  enlightened  part  of  the  civilized  world. 
It  would  be  idle  to  enter  into  all  the  details  suggested  by  igno- 
rance, or  craft,  for  the  due  performance  of  navel-dressing.  A 
variety  of  medicaments  were,  and  in  some  places  are  still  in  use 
for  this  purpose;  all  of  which,  to  say  the  least  of  them,  are  alto- 
gether unnecessary.  The  only  necessity  for  applying  anything 
to  this  part  is,  to  prevent  the  dead  navel-string  from  coming  in 
contact  with  the  skin  of  the  child;  it  would  therefore  matter  not, 
as  regard  the  cord  itself,  if  it  were  not  touched  by  any  dressing. 
Dress  it  as  we  may,  it  will  always  separate  at  the  umbilicus;  and 
our  whole  care  should  be  to  prevent  this  putrefying  mass  from 
excoriating  the  skin.  Though  the  dressing  of  the  navel  is  not 
strictly  the  accoucheur's  province,  nevertheless  as  it  may  be  re- 
quired of  him,  he  must  not  be  ignorant  upon  a  subject,  to  which 
the  world  at  large,  attaches  so  much  consequences,  however 
lightly  he  himself  may  think  of  it. 

595.  All  that  is  necessary,  is,  to  pass  the  remaining  portion  of 
the  cord  through  a  hole  in  the  centre  of  a  piece  of  linen  rag,  seven 
or  eight  inches  in  length,  and  about  two  and  a  half  broad.  After  the 
cord  has  been  passed  through,  it  must  be  enveloped  entirely  by  a 
bandage  of  ten  inches  long,  and  rather  less  than  an  inch  broad, 
by  passing  it  round,  its  whole  length.  The  pierced  piece  of  rag 
is  placed  lengthwise,  as  regards  the  child's  body;  on  this  the 
wrapped  up  cord  is  laid,  with  its  extremity  towards  the  breast  of 
the  child;  the  inferior  portion  of  the  first  rag  is  then  folded  over 
it,  and  the  whole  secured  by  the  belly-band;  after  this,  the  child 
is  dressed  as  fancy  directs,  or  as  circumstances  may  force. 

c. — Purgiiig  off  the  Meconium,  4*c. 

596.  The  propriety  of  purging  off  the  meconium  is  no  longer 
doubted;  especially,  in  hot  climates.  It  has  been  found  very 
much  to  lessen  the  mortality  among  the  new-born  children  of  the 
West  Indies,  and  other  similar  climates,  by  preventing  that  very 
common,  and  but  too  often  fatal  disease,  called  the  jaw-fall,  or 
the  trismus  nacentium.  This  practice  should  never  be  neglect- 
ed, even  in  this  country.  It  might  be  difficult  to  say  exactly,  of 
what  the  meconium  is  composed;  but  it  would  seem  certain,  that 
bile  is  one  of  its  constituent  parts,  agreeably  to  the  analysis  of 
Vauquelin  ;  and  the  other,  in  part,  is,  the  recrement  of  the  secre- 
tion from  the  mucous  membrane  of  the  intestines;  the  finer  parts 


PURGING  OFF  THE  MECONIUM.  215 

having  been  absorbed.*  This  substance  is  sometimes  of  very  con- 
siderable tenacity,  and  a  dark  bottle-green;  this  colour  is  de- 
rived from  the  admixture  of  bile. 

597.  For  the  purpose  of  carrying  off  this  substance,  it  is  found 
that  a  little  molasses  and  warm  water  is  generally  sufficient;  I 
always  order  two  or  three  tea-spoonsful  to  be  given  at  once,  and 
repeated  from  time  to  time,  if  the  previous  quantity  be  not  suffi- 
cient— this  rarely  fails;  especially,  when  aided  by  the  early  se- 
cretion of  the  mother's  milk.,t  Should  this  fail,  the  child  becomes 
fretful  and  uneasy;  and  oftentimes  will  moan,  or  cry  loudly;  be- 
come sleepy;  frequently  start;  and  by  its  complainings,  show  it- 
self to  be  ill  at  ease.  When  we  find  this  to  be  the  case,  we  should 
inquire  into  the  state  of  the  evacuations;  and  if  these  have  not 
been  sufficiently  liberal,  which  is  easily  determined  by  their  con- 
tinuing to  be  tenacious  and  green,  we  should  direct  a  small  tea- 
spoonful  of  warm  castor  oil ;  this  must  be  repeated,  should  it  not 
operate  in  a  couple  of  hours;  or  a  mild  injection  of  warm  milk 

•  It  would  seem  to  be  proved,  by  a  case  related  by  Dr.  Rees  (on  Costiveness, 
p.  137.)  on  the  authority  of  Mr.  Hallam,  that  the  meconium  is  a  combination  of 
the  recrement  of  some  digestion,  perhaps  bile,  and  a  peculiar  secretion  from  the 
intestines  themselves,  (but  perhaps,  especially  of  the  colon)  and  not  the  remains 
of  food  taken  in  after  birth,  or  as  some  have  supposed,  of  nourishment  received 
by  the  mouth  dui-ing  the  stay  of  the  foetus  in  utero.  Mr.  H.  delivered  a  patient 
of  a  *'  fine  muscular,  fat,  and  healthy  child,  which  had  an  impervious  oesopha- 
gus, so  that  no  food  ever  passed  into  the  stomach.  The  child  Uved  thirteen  days; 
but  was  so  wasted  that  its  skin  hung  like  a  loose  garment,  and  could  be  lapped 
and  folded  over  its  limbs.  At  first  the  child  discharged  the  usual  quantity  of 
meconium  from  the  bowels,  and  afterwards  had,  during  eight  days,  one  or  two 
alvine  discharges,  in  quantity,  colour,  and  consistence,  not  distinguishable  from 
the  stools  of  children  who  took  food  in  the  usual  manner.  After  the  eighth  day 
tlie  faecal  discharges  became  more  scanty  and  less  frequent,  but  they  continued 
to  the  last." 

A  similar  case  has  just  fallen  under  my  own  observation.  A  child  was  born 
with  every  external  appearance  of  healthy  conformation — but  upon  attempting 
to  give  it  a  little  molasses  and  water  it  had  nearly  strangled.  Upon  looking  into 
its  mouth  it  was  discovered,  there  was  no  vault  to  it;  neither  was  there  a  ves- 
tige of  soft  pallet.  It  never  swallowed  a  drop — indeed  every  attempt  was  fol- 
lowed by  such  terrible  distress,  by  the  fluid  passing  into  the  trachea,  that  the 
trial  was  abandoned.  It  lived  however  ten  days — ^became  extremely  emaciated 
and  very  yellow;  yet  it  passed  the  meconium  freely;  after  which  the  evacua- 
tions were  yellow. 

f  This  is  an  additional  argument,  for  the  early  apf)lication  of  the  cluld  to  the 
breast;  since  the  first  secretion  of  the  breasts  is  of  a  purgative  quality.  This 
product  is  called  "  Colostrum." 


216  OP  THE  RETENTION  OP  URINE. 

and  water,  with  some  molasses  dissolved  in  it;  will  answer  very 
well  to  aid  the  action  of  the  oil. 

598.  I  must  earnestly  protest  against  the  use  of  any  acrid  pur- 
gative, for  the  purpose  of  carrying  off  the  meconium — nurses  and 
midwives  are  too  apt  to  employ  them,  when  this  part  of  our  duty 
is  left  to  their  discretion.  I  therefore  make  it  a  rule  to  point  out 
the  remedy  to  be  employed,  without  permitting  them  the  smallest 
latitude.  Their  ignorance  frequently  betrays  them  into  indiscre- 
tions; and  this  sometimes  to  the  absolute  injury  of  the  child.  I 
have  too  frequently  witnessed  this,  not  to  feel  it  a  duty  to  inveigh 
most  pointedly  against  it. 

599.  Dr.  Buchan,  in  his  pleasant  and  useful  little  work,  "Ad- 
vice to  jNTothers,"  relates  an  anecdote  so  much  in  point,  that  I  am 
induced  to  quote  it  at  length;  "I  was  once  sent  for  by  an  inti- 
mate friend,  to  look  at  a  new  born-infant,  who  appeared  to  be  in 
great  agony.  I  soon  discovered  the  complaint  was  the  belly-ache, 
caused  by  some  injudicious  purgative.  As  the  midwife  was  pre- 
sent, I  remonstrated  with  her  on  the  rashness  of  thus  tampering 
with  an  infant's  delicate  constitution.  She  replied,  in  a  tone  of 
self-sufficiency  and  surprise,  'Good  God!  Doctor,  I  only  gave  the 
proper  medicine  to  carry  away  the  economy.''''  I  should  have 
smiled  at  her  affectation  of  medical  cant,"  adds  the  Doctor,  ''and 
her  ridiculous  attempt  to  catch  the  word  7neconiu7n,  had  not  the 
serious  mischief  she  had  done  repressed  every  motion  of  laugh- 
ter." A  medical  friend  told  me  some  time  since,  that  he  was 
called  to  a  newly-born  infant,  which  was  dying  in  great  agony 
from  a  dose  of  aloes,  exhibited  by  the  midwife. 

600.  There  is  oftentimes  much  mischief  arising  from  over- 
purging  newly-born  infants;  they  therefore  not  only  require  very 
mild  remedies,  but  proper  doses  of  such  remedies — and  there  is 
one  rule  by  which  these  exhibitions  should  always  be  governed ; 
namely,  that  so  soon  as  there  is  a  change  in  the  colour  of  the 
evacuations,  all  purgative  medicines  should  instantly  be  withheld. 

d.  —  Of  the  Retention  of  Urine. 

601 .  It  very  frequently  happens  with  newly-born  children,  that 
they  do  not  pass  their  urine  for  many  hours  afterbirth;  or  so 
sparingly  as  to  afford  little  or  no  relief;  this  creates  a  great  deal 
of  distress,  and  if  not  relieved  by  proper  means,  will  sometimes 
occasion  death.  A  very  remarkable  instance  of  this  kind  fell  un- 
der the  notice  of  my  friend  Dr.  Parrish,  and  myself,  which  I  will 


OP  THK  RETENTION  OF   UKINE.  217 

give  in  detail.     Mrs. was  delivered  of  a  healthy  baby  on  the 

15th  June,  1822.  On  the  20th,  in  the  evening,  the  child  showed 
uneasiness,  and  on  the  21st  it  cried  violently,  and  continued  to  be 
much  pained  until  the  25th.  A  variety  of  simple  means  were  in- 
effectually used  for  the  discharge  of  the  urine,  which  had  been 
either  very  sparing,  or  entirely  suppressed,  most  probably  from 
the  20th.  On  the  morning  of  the  25th,  at  ten  o'clock,  we  found 
the  abdomen  very  much  distended,  even  to  the  scrobiculus  cor- 
dis; the  skin  shining,  and  the  superficial  veins  very  much  en- 
larged. The  child  had  several  very  sparing  stools,  of  a  very  dark 
green  colour:  two  tea-spoonsful  of  castor  oil  were  given  in  the 
course  of  the  morning.  At  half  past  one  o'clock,  P.  M.  Dr. 
Parrish  introduced  a  small  flexible  catheter  and  drew  off  at  one 
time  eighteen  ounces  and  a  half  of  a  straw-coloured  urine.  At 
seven  o'clock  of  the  same  day,  the  child  appeared  perfectly  reliev- 
ed; it  slept  soundly,  and  took  nourishment  freely;  two  more  tea- 
spoonsful  of  castor  oil  had  been  given  since  the  visit  at  noon,  but 
without  moving  the  bowels,  nor  did  any  water  pass — as  the  child 
was  easy,  it  was  permitted  to  rest  without  disturbance. 

602.  From  this  time  until  it  died,  (on  the  28th,)  the  water  was 
regularly  drawn  off  by  the  catheter;  the  child,  however,  gradu- 
ally declined  from  our  first  visit;  and  its  mouth  became  very 
sore;  leave  was  not  obtained  to  examine  it. 

603.  I  have  recorded  this  case  for  its  great  practical  importance. 
I  have  seen  several  instances  similar  in  their  general  appearances, 
and  terminations;  vv'hich  gives  me  strong  reason  to  believe,  that 
these  children  may  have  died  of  a  retention  of  urine,  though  I  was 
assured  that  they  had  regularly  passed  water — such  was  the  state- 
ment for  awhile,  in  the  case  just  related;  and  perhaps  there  may 
have  been  a  small  discharge,  as  always  happens  when  the  bladder 
becomes  excessively  distended.  This  often  takes  place  in  the 
adult,  from  the  same  cause;  it  is  therefore  a  good  rule  to  inquire 
into  the  state  of  the  bladder,  in  all  the  complaints  of  very  young 
children ;  and  we  must  not  be  too  easily  satisfied  with  the  re- 
ports of  the  nurse  upon  this  subject — I  now  make  it  my  business, 
whenever  I  have  any  suspicion  that  the  urine  is  not  freely 
evacuated,  to  examine  the  abdomen  of  the  child,  especially  if  it 
be  reported  to  be  swelled.  I  carefully  examine  the  region  of  the 
bladder,  with  a  view  to  detect  any  distention  of  it,  that  I  may 
take  measures  accordingly.  I  am  disposed  to  believe,  had  the 
catheter  been  introduced  twenty-four  hours  sooner,  nay,  perhaps 

28 


218  OF  FOOD  FOR  THE  CHILD. 

twelve,  the  infant,  whose  case  is  related  above,  might  have  been 
saved — but  as  there  was  a  constant  assurance  that  water  passed, 
there  was  no  suspicion  of  the  state  of  the  bladder.* 

604.  I  suggest,  as  a  matter  of  probability,  that  the  cases  I 
have  witnessed  of  death  in  very  young  children,  where  the  ab- 
domen has  been  much  svvoln;  the  superficial  veins  passing  over 
it  much  distended,  and  very  conspicuous,  were  similar  affec- 
tions of  the  bladder,  though  no  such  suspicion  was  entertained  at 
the  time.  How  far  a  distended  belly,  (indeed  almost  to  transpa- 
rency,) with  greatly  enlarged  veins,  may  serve  to  distinguish 
this  state  of  the  urinary  organs  in  very  young  children,  must  be 
left  to  future  observation.  I  felt  it  a  duty  to  express  this  im- 
pression, with  a  hope  it  might  awaken  attention  in  those,  whose 
province  it  is,  to  witness  many  cases  of  sickness;  especially,  in 
very  young  children. 

Sect.  YWl.— Of  Food  for  the  Child. 

605.  The  mother  very  rarely  has  her  breasts  furnished  with 
milk,  at  the  birth  of  the  child;  for  the  most  part,  there  is  an  inter- 
val of  several  days,  before  it  is  supplied  in  sufficient  quantity,  to 
sustain  the  infant — it  is  therefore  supposed,  that  the  child 
would  suffer  severely,  did  it  not  receive  nourishment  by  other 
means,  until  the  mother  is  enabled  to  ^rom't/e  for  it.  According- 
ly, an  ample  bowl  is  prepared  by  the  nurse ;  and  the  stomach  of  the 
child  is  crammed  to  regurgitation,  with  a  tenacious  paste,  called 
pap,  or  panada.  This  is  repeated  with  such  mischievous  indus- 
try, as  to  throw  the  poor  infant  into  violent  agony,  unless  its  sto- 
mach revolt  at  the  unmerciful  invasion,  and  rejects  it  by  a  violent 
effort,  and  thus  averts  the  impending  mischief  Nature  seems  to 
have  endowed  the  stomachs  of  children  with  a  discriminating 

*  "The  introduction  of  the  catheter  is  spoken  of,  in  the  case  of  a  child  ten 
days  old.  We  never  have  had  occasion  to  employ  the  instrument  at  so  early 
an  age,  and  fear  that  its  employment  is  more  easily  described  on  paper  than 
carried  into  execution  in  practice,  particularly  in  the  male."  {Lond.  Med.  and 
Phys.  Journ.  Aug.  p.  149.) 

In  a  case  similar  to  the  one  which  gave  rise  to  the  above  observation,  it  may 
be  asked,  what  other  resource  does  our  art  afford?  I  have  not  declared,  nor 
even  insinuated,  that  the  catheter  should  be  used  upon  slight  occasions:  but 
where  the  suppression  is  confirmed,  and  where  every  usual  expedient  has  been 
resorted  to,  and  has  failed,  should  we  suffer  our  patient  to  die,  because  the  in- 
troduction of  the  catheter  is  difficult!' 


OP  FOOD  FOR  THE  CHILD.  219 

power  upon  such  occasions;  and  most  happy  it  is  for  them  that 
she  has  been  thus  kind  ;  for,  were  it  otherwise,  many  would  die 
in  a  few  hours  after  birth,  from  absolute  repletion. 

606.  It  appears  that  the  kind  nurse  has  but  one  rule,  by  which 
she  regulates  the  feeding  of  a  newly-born  child;  which,  is,  to 
pour  food  down  its  throat  until  its  stomach  can  hold  no  more;  it 
is  then  permitted  to  rest  a  short  time.  But  the  delightful  task  of 
cramming,  is  again  resumed;  especially,  if  the  poor  babe  cry ; 
it  is  now  imagined  to  be  again  hungry,  and  again  its  feeble 
powers  of  digestion  are  unmercifully  taxed.  This  addition  of 
food,  to  the  great  surprise  of  the  anxious  nurse,  does  not  quiet 
its  complainings;  and  its  uneasiness  is  now  attributed  to  "  wind;" 
and  the  unfortunate  child  is  next  obliged  to  swallow  some 
stimulating  tea,  or  liquor,  until  further  distention,  and  perhaps 
intoxication,  are  added  to  the  already  almost  bursting  stomach. 
It  is  then  rudely  jolted  on  the  knee,  until  a  kind  vomiting  comes 
to  its  relief;  or  until  the  bowels,  rapidly  and  profusely  discharge 
their  contents,  or  until  convulsions  close  the  scene. 

607.  Let  us  consider  for  a  moment  how  small  the  stomach  of  a 
newly-born  child  is;  and  how  little  will  put  it  upon  an  uneasy 
stretch — passive,  during  the  whole  period  of  utero-gestation,* 

•  Dr.  C.  Lee  has  been  making  some  interesting  inquiries  into  the  nature  of 
the  digestive  process  in  the  foetus  while  in  utero,  and  upon  which,  he  has  come 
to  the  following  conclusions;  that,  "there  is  a  digestive  process  carried  on  in 
the  upper  intestines  of  the  foetus,  similar  to  that  which  takes  place  after  birth : 
and  that  the  nutrition  and  growth  of  the  foetus,  are  chiefly,  or,  perhaps  entirely, 
effected  Intliis  manner."  He  has  ascertained,  that  "the  stomach  of  the  foetus, 
from  three  to  nine  months  old,  invariably  contains  a  transparent  mucus  and  acid 
fluid,  but  never  the  smallest  admixture  of  albuminous  or  nutritious  matter,  while 
on  the  other  hand,  the  upper  half  of  the  small  intestines  always  contains  a  yel- 
lowish or  orange-coloured  pultaceous  mass,  which,  in  appearance,  as  well  as 
chemical  composition,  resembles  exactly  the  chyme  of  the  adult;  in  a  word,  that 
it  is  nearly  pui-e  albumen.  The  contents  of  the  lower  half  of  the  small  Intestines, 
contain  a  much  smaller  proportion  of  albumen,  than  those  of  the  upjier  half,  and 
the  matters  gradually  assume  more  and  more  the  characters  of  the  contents  of 
the  large  intestines,  in  proportion  as  the  distance  from  the  valve  of  the  colon 
diminishes." 

A  fluid  resembling  that  contained  in  the  duodenum,  has  been  detected  in  the 
hepatic  ducts  of  the  foetus;  from  which  it  Is  inferred,  that  the  liver  of  the  foetus 
secretes  the  nutritious  matter.  This  conjecture  appears  to  be  strengthened, 
from  the  great  comparative  size  of  the  Uver  In  the  foetus;  and  that  this  organ 
has  never  been  found  wanting  in  any  case  of  monstrosity  yet  examined. — Lond. 
Med.  and  Phys,  Journal,  for  September,  1827. 
These  facts  show  us  how  extremely  small,  and  unused  to  distention,  the  sto- 


220  OF  FOOD  FOR  THE  CHILD. 

and  contracted  to  its  minimum  size;  it  is  no  sooner  born  than  it 
is  obliged  to  submit  to  be  suddenly  distended  to  almost  giving 
way,  from  mistaken  zeal.  Can  it  then  be  a  matter  of  surprise, 
that  so  many  children  are  subject  to  pain,  spasms,  convulsions, 
and  even  death,  a  few  days  after  they  are  born  ? 

608.  What  is  the  proper  food  for  a  child  at  this  period? — or 
should  it  have  any?  There  can  be  no  objection  to  nourishment 
from  time  to  time  meted  in  proper  quantities,  and  composed  of 
proper  materials.  It  must  be  recollected,  that  the  nearer  we 
follow  nature  in  such  cases,  the  nearer  we  approach  to  what  is 
right;  nature  provides  milk  as  early  as  circumstances  will  per- 
mit, and  milk  only — so,  on  our  parts,  we  can  imitate  her  provi- 
dence sufficiently  near,  to  prevent  mischief;  and  only  milk 
should  be  given,  until  the  mother  herself  be  capable  of  furnish- 
ing adequate  supplies.  The  article  I  am  in  the  habit  of  recom- 
mending, is,  cow's  milk  diluted  with  one-third  water,  with  the 
addition  of  a  little  loaf  sugar.  Of  this,  the  youngest  child  may 
take  a  few  tea-spoonsful  at  a  time,  and  this  to  be  repeated  as  oc- 
casion may  require. 

609.  The  vulgar,  judge  of  the  nutritious  quality  of  a  sub- 
stance, principally  by  its  density;  hence,  they  are  opposed  to 
the  simple  food  just  recommended,  because  it  does  not  possess 
this  quality;  and  they  insist  upon  improving  it,  by  the  addition 
of  some  farinaceous  article,  but  by  which  it  is  sure  to  be  deterio- 
ated:  for  almost  all  the  children  who  partake  of  this  improved 
substance,  are  sure  to  be  afflicted  with  green  and  watery  stools, 
if  not  with  a  full  crop  of  aphthse.  But,  so  soon  as  the  mother 
is  able  to  supply  the  demands  of  her  infant,  it  should  be  con- 
fined to  the  product  of  her  breasts;  and  to  that  alone;  cseteris 
paribus. 

610.  Many  of  the  preparations  in  use  as  nourishment  for  young 
children,  cannot  be  too  strongly  condemned;  such  as  crackers  and 
water  boiled  together,  and  sweetened;  or  bread,  water,  and  su- 
gar; than  which  nothing  can  be  more  ungenial  to  the  infant  sto- 
mach— for  these  masses  begin  to  ferment  the  instant  they  are  re- 
ceived into  the  stomach.  Green  and  watery  stools,  amounting  in 
fact  to  diarrhoea,  colic,  sour  eructations,  or  throwing  up  their 

mach  of  the  new-bom  child  is;  and  warn  us  to  be  cautious  not  to  put  it  too 
suddenly  upon  the  stretch.  They  put  to  flight,  besides,  the  agency  of  the 
liquor  amnii  in  foetal  nutrition;  and  satisfactorily  account  for  the  recrement, 
called  "meconium." 


./< 


ON  NATURAL  OR  UNASSISTED  LABOUR.  221 

milk  strongly  curdled,  are  almost  the  constant  result  of  their  em- 
ployment. Besides,  we  must  object  upon  general  principles,  to 
the  use  of  any  substance,  which  needs  to  be  made  so  warm  as  to 
require  tempering  for  the  child's  mouth,  by  first  entering  that  of 
the  nurse.  This  is  a  horrible  practice,  and  cannot  be  too  severe- 
ly reprobated.  The  child  is  thus  obliged  to  take  into  its  ill-con- 
firmed stomach,  food,  not  only  improper  in  itself,  but  which  has 
the  addition  of  a  rank  saliva  from  the  nurse's  mouth. 

611.  Much  care,  we  grant,  must  betaken  in  warming  the  food 
of  the  child,  lest  it  be  overheated,  and  its  mouth  made  to  pay  the 
forfeit  of  the  nurse's  carelessness;  but  this  can  be  done  without 
any  previous  mouthing. 


CHAPTER  XV. 

ON  NATURAL  OR  UNASSISTED  LABOUR. 

612.  The  classification  of  labours  is  altogether  arbitrary;  scarce- 
ly two  writers  agreeing  upon  the  same  arrangement.  The  object 
of  every  classification,  is  to  aid  the  memory  by  tracing  analogies; 
to  establish  general  rules  from  which  particular  ones  may  be  de- 
duced, and  for  the  convenience  of  description.  Now  these  ends 
appear  to  be  answered  by  almost  any  division  that  we  may  adopt, 
starting  with  some  general  definitions,  and  making  everything,  as 
far  as  may  be,  conform  to  the  g3neralization.  There  cannot,  there- 
fore, be  any  one  employed  which  may  not  be  liable,  some  to  more, 
and  others  to  fewer,  exceptions.  I  have  carefully  considered  them 
all — some  I  would  reject  for  their  learned  parade,  without  cor- 
responding perspicuity;  others,  for  their  complication,  and  the 
want  of  harmony  in  their  parts ;  others,  for  their  multiplied  dis- 
tinctions without  essential  difierences;  and  others,  for  the  incor- 
rectness of  their  definitions;  experience  being  constantly  at  vari- 
ance with  them. 

613.  The  one  in  my  estimation  least  liable  to  objection,  is  that 
of  Baudelocque — I  am  persuaded  that  more  correct  practical  no- 
tions can  be  collected  by  a  proper  study  of  his  arrangement,  than 
from  any  other;  and  I  am  also  certain,  that  the  younger  practi- 
tioner well  acquainted  with  his  system,  when  placed  at  the  bed- 


222  ON  NATURAL  OR  UNASSISTED  LABOUR. 

side,  will  give  a  more  correct  view  of  any  given  case;  will  feel  less 
embarrassment  in  deciding  on  the  proper  mode  of  treating  that 
case,  and  will  commit  fewer  mistakes  in  the  absolute  management 
of  it,  than  from  the  study  of  any  other  classification.  In  my 
view  it  is  as  perfect  as  the  nature  of  things  will  permit;  and  I 
therefore,  from  acting  under  it  for  many  years,  have  adopted  it. 
In  pursuing  this  plan,  I  shall  constantly  feel  that  I  am  abridging 
the  labour  of  the  student;  removing  many  of  the  difficulties  of 
the  young  practitioner;  and  confirming  the  observations  of  the 
experienced."* 

614.  A  number  of  circumstances  must  concur  that  a  woman 
carry  her  child  to  the  full  period  of  utero-gestation,  and  then  give 
birth  to  it  with  the  least  possible  trouble  and  risk.  To  secure  the 
first,  she  must  be  free  from  every  cause  capable  of  exciting  the 
uterus  to  action ;  or  at  least  to  that  degree  of  action,  that  would 
terminate  in  labour.  And,  for  the  latter,  there  must  be  present 
in  the  uterus  itself,  a  healthy  disposition  to  action;  and  that  dis- 
position manifested,  previously  to  the  commencement  of  labour, 
properly  so  called,  by  the  subsiding  of  the  uterus  lower  in  the  pel- 
vis; by  a  secretion  of  mucus ;  by  a  kindly  disposition  in  the  circular 
fibres  of  the  uterus  to  relax,  that  the  longitudinal  need  not  be  fa- 
tigued by  too  long  acting;  and  these  contractions  must  be  sufficient- 
ly powerful  to  make  the  child  pass  through  the  pelvis.  There  must 
also  be  a  disposition  in  the  external  parts  to  yield,  without  the 
agency  of  much  mechanical  force;  there  must  exist  a  proper  pro- 
portion between  the  opening  of  the  pelvis,  and  the  diameter  of 
the  child's  head  ;  and  the  latter  must  be  well  situated,  that  it  may 
profit  by  the  proper  construction  of  the  former;  or,  in  other 
words,  the  great  diameter  of  the  child's  head  must  constantly 
correspond  with  the  great  diameter  of  the  pelvis. 

615.  As  all  the  circumstances  essential  to  an  easy  and  natural 
labour  cannot  be  commanded,  it  must  follow,  that  there  will  con- 
stantly be  deviations  from  it;  and  these  deviations  must  be  looked 
upon  as  so  many  exceptions  to  the  several  presentations,  which 
Baudelocque  makes  necessary  to  a  natural  labour.  Baudelocque 
considers  every  labour  natural,  in  which  the.  woman  might  be  de- 
livered without  help;  and  makes  such  consist  of  four  principal 
presentations;  namely,  1st,  the  head  ;  2d,  the  feet;  3d,  the  knees, 
4th,  the  breech. 

•  Though  I  have  adopted  Baudelocque's  general  arrangement,  I  have  not 
rigorously  confined  myself  to  it.  This  will  be  readily  perceived,  from  the 
manner  in  which  I  have  treated  the  various  presentations. 


ON  NATURAL  OR  UNASSISTED  LABOUR.  223 

616.  It  would  be  reasonable  to  conclude,  that  the  presentations 
which  most  frequently  occur,  are  the  most  natural:  now  these  are 
found  to  consist  of,  1st,  those  cases  in  which  the  child  presents  the 
head ;  2d,  those  in  which  the  breech  offers  ;  3d,  those  in  which 
the  feet  offer  ;  4th,  those  in  which  the  knees  offer.*  Each  of 
these  genei-al  presentations  are  subdivided  and  form  varieties. 

617.  Baudelocque  is  censured  by  some  for  the  detail  he  enters 
into  when  speaking  of  his  general  presentations,  and  his  subdivi- 
sions of  them  ;  but  in  this  their  censure  is  misapplied.  Every  prac- 
titioner who  is  well  acquainted  with  the  form  and  dimensions  of 
the  pelvis  ;  with  the  construction  and  various  dimensions  of  the 
child's  head  ;  and  with  the  mechanism  of  each  individual  labour; 
will  be  so  far  from  condemning  him,  that  he  will  admit  that  no 
man  can  practise  with  entire  success,  or  complete  usefulness, 
without  a  thorough  knowledge  of  them,  I  agree,  that  to  certain 
practitioners  it  will  not  only  appear  useless,  but  burthensome — 
those,  for  instance,  who  commit  the  whole  charge  of  the  labour 
to  the  management  of  nature,  provided  the  head  present,  and  this 
no  matter  how;  and  as  she  is  usually  successful,  never  stop  to  in- 
quire whether  they  can  aid  her  efforts,  or  abridge  her  toils  :  or 
those  who  consider  the  presentation  of  any  one  of  the  other  parts 
above  designated  as  essentially  wrong  ;  and  who  will,  in  conse- 
quence, wrest  from  the  hands  of  nature,  a  labour,  to  terminate  it 
by  force,  when  she  was  every  way  competent  to  its  accomplish- 
ment. Against  the  cavilings  of  such  practitioners,  I  do  not  think 
it  worth  the  trouble  to  defend  him. 

618.  As  regards  myself,  1  am  willing  to  confess,  for  the  know- 
ledge I  possess  upon  the  subject  of  midwifery,  I  am  principally 
indebted  to  him:  for  to  him  do  I  owe  the  principles  which  ren- 
dered my  experience  profitable  ;  and  could  I  induce  others  who 
engage  in  the  practice  of  midwifery,  to  carefully  study  this  great 
man's  works,  I  should  benefit  society,  by  rendering  practitioners 
so  much  the  more  competent  to  fulfil  the  duties  they  have  under- 
taken to  discharge.  Entertaining  such  sentiments  of  the  author 
I  intend  chiefly  to  follow,  I  shall  not  deem  it  necessary  to  apo- 
logize for  my  choice. 

•  For  the  reason  just  assigned,  I  have  changed  the  order  of  Baudelocque's 
arrangement  of  the  presentations  constituting  *«  natural  labour."  The  fre- 
quency of  the  comparative  occurrence  of  the  several  presentations  named 
above,  will  I  beUeve  be  found  pretty  constantly  to  stand  in  the  order  I  have 
now  placed  them  ;  and  this,  in  my  estimation,  should  be  taken  as  the  rule  of 
division. 


224         ON  THE  PRESENTATIONS  OF  THE  HEAD. 

619.  In  speaking  of  the  presentations  of  the  head,  I  confine 
myself,  like  Baudelocque,  to  those  portions  of  it  designated  by 
the  name  of  the  vertex  or  the  posterior  fontanelle,  and  to  that  of 
the  anterior  fontanelle;  or  in  other  words,  the  particular  or  spe- 
cific presentation,  is  always  indicated  by  these  portions  of  the 
cranium.  And  when  neither  of  these  offer,  so  as  to  characterize 
the  presentation,  the  part  most  easy  to  touch  in  the  pelvis  will 
always  be  designated  by  its  own  name ;  and  all  such  will  be  con- 
sidered as  deviations  from  the  presentations  of  the  head,  properly 
so  called. 


CHAPTER  XVI. 

OP  THE  PRESENTATIONS  OP  THE  HEAD. 

620.  The  frequency  with  which  the  head  presents,  compared 
with  any  other  part  of  the  body,  renders  its  various  positions  bet- 
ter known;  and  also  entitles  them  to  be  considered  as  the  most 
natural:  yet  even  head  presentations  have  essential  difierences, 
as  they  are  not  all  equally  advantageous.  Therefore  each  variety 
should  be  well  studied  ;  its  distinguishing  marks  well  ascertained, 
and  its  mechanisms  thoroughly  comprehended. 

621.  These  presentations  will  be  divided  into  six  varieties  ; 
each  of  which  has  peculiar  characteristics: — In  the  first  presenta- 
tion, 7;o5/erior/on/«/iff//e  is  behind  the  left  acetabulum,  and  the 
anterior  before  the  right  sacro-iliac  symphysis  ;  the  head,  there- 
fore, is  placed  diagonally  as  regards  the  superior  strait;  so  also  is 
the  case  in  the  second,  fourth,  and  fiflh.  In  the  second  presenta- 
tion, the  posterior  fontanalle  is  behind  the  right  acetabulum, 
and  the  anterior  before  the  left  sacro-iliac  symphysis.  In  the 
third,  the  posterior  fontanelle  is  placed  behind  the  symphysis 
pubis,  and  the  anterior  before  the  projection  of  the  sacrum — in 
this,  and  in  the  sixth  presentation,  the  great  diameter  of  the 
child's  head  offers  itself  parallel  with  the  small  diameter  of  the 
superior  strait.  In  the  fourth,  the  anterior  fontanelle  is  behind 
the  left  acetabulum,  and  ihe  posterior  before  the  right  sacro-iliac 
symphysis.  In  the  fifth,  the  anterior  fontanelle  is  behind  the 
right  acetabulum,  and  the  posterior  before  the  left  sacro-iliac 
symphysis.     The  sixth  is  the  reverse  of  the  third. 

622.  Some  have  objected  to  these  divisions,  1st,  as  being  per- 


THE  FIRST  PRESENTATION.  225 

plexing  to  the  memory;  2(],  and  this  without  conveying  any  es- 
sential practical  information.  To  the  first,  it  may  be  answered, 
that  the  whole  of  them  can  be  learned,  by  pursuing  the  course  I 
shall  lay  down,  as  quickly  almost  as  they  can  be  read;  and  the 
same  observation  will  apply  to  all  the  other  varieties  of  natural 
labour. 

623.  Let  it  be  remembered;  first,  that  the  1,  2,  and  3  presen- 
tations of  the  head,  are  all  represented  by  W\q posterior  fontanelle; 
and  the  4,  5,  and  6,  by  the  anterior  fontanclh:  second;  that  in 
describing  these  presentations,  we  constantly  follow  their  nume- 
rical order:  third;  that  we  always  commence  with  the  left  aceta- 
bulum; then  go  to  the  right  acetabulum,  and  next  to  the  symphy- 
sis pubis,  whether  it  be  the  posterior  fontanelle  or  the  anterior, 
that  is  to  be  represented — this  will  make  the  first  presentation 
have  the  posterior  fontanelle  behind  the  left  acetabulum,  the  se- 
cond behind  the  right  acetabulum,  and  the  third  behind  the  sym- 
physis pubis.  Then,  as  I  have  just  stated,  the  other  three  take 
their  character  from  the  anterior  fontanelle,  and  follow  precisely 
the  same  route,  or  order — of  course,  the  fourth  will  have  the  an- 
terior fontanelle  to  the  left  acetabulum,  the  fifth  to  the  right  ace- 
tabulum, and  the  sixth  to  the  symphysis  pubis. 

624.  As  regards  the  second  objection,  that "  this  division  con- 
veys no  essential  practical  information,"  I  can  only  lament  the 
imperfect  knowledge  of  the  objector  of  what  is  absolutely  required 
of  every  one  who  attempts  to  pursue  midwifery,  if  he  cannot  pro- 
fit, and  that  materially,  by  the  divisions  and  distinctions  of  Baude- 
locque;  for  I  maintain,  that  the  excellence  of  one  accoucheur 
over  that  of  another,  almost  exclusively  depends  upon  the  accu- 
racy of  his  knowledge  of  the  different  presentations. 

625.  I  have  already  earnestly  recommended  to  the  inexperi- 
enced practitioner,  to  study  the  different  pi-esentations  carefully; 
and  to  take  the  fontanelles,  and  not  the  ears,  for  his  guide.  (89) 
The  vertex,  therefore,  will  be  distinguished  from  any  other  part, 
by  its  roundness,  its  firmness,  its  sutures,  and  its  fontanelle.  The 
particular  position  of  the  head  relatively  to  the  pelvis,  (and  this 
constitutes  the  species  of  presentation,)  is  only  to  be  determined 
by  the  position  of  the  fontanelles,  and  the  direction  of  the  su- 
tures; to  determine  this,  however,  it  is  only  necessary  to  ascer- 
tain the  situation  of  the  fontanelles. 

29 


22G  THE  FIRST  PRESENTATION. 

Sect.  I. —  Of  the  first  Presentation,  and  its  Mechanism. 

626.  In  the  first  presentation,  the  posterior  fontanelle  places 
itself  behind  the  left  acetabulum,  while  the  anterior  offers  before 
the  right  sacro-iliac  junction:  the  sagital  suture  must,  therefore, 
traverse  the  superior  strait  obliquely.  For  the  position  of  the 
trunk  and  other  parts  of  the  child,  I  refer  to  plate  V.  and  expla- 
nation, at  the  end  of  the  volume. 

627.  The  head  of  the  child  in  this  presentation  offers  itself  in 
an  oblique  position  as  regards  the  superior  strait;  by  the  contrac- 
tions of  the  uterus  the  vertex  is  made  to  sink  lower  in  the  pelvis 
than  any  other  portion  of  the  head,  and  at  the  same  time  places 
the  chin  of  the  child  upon  its  breast.  The  head  descends  in  this 
state  of  anterior  iiexion,  in  the  axis  of  the  superior  strait,*  until 
it  is  arrested  by  the  sacro-ischiatic  ligaments  of  the  left  side,  the 
sacrum  and  perinseum.  When  the  head  arrives  at  this  first  part, 
it  would  remain  stationary,  did  not  its  relations  with  the  pelvis  at 
the  lower  strait,  change  in  such  manner  as  to  force  the  posterior 
fontanelle  to  offer  itself  to  the  arch  of  the  pubes — in  doing  this, 
there  is  a  slight  twist  or  pivot-like  motion  executed  at  the  ex- 
pense of  the  neck,  which  may  be  estimated  at  a  sixth  or  eighth 
of  a  circle.  During  this  change  in  the  direction  of  the  head,  it 
must  be  recollected,  that  the  trunk  does  not  perform  a  similar 
movement. 

628.  In  proportion  as  the  head  is  urged  forward,  the  lamboidal 
suture  is  to  be  more  distinctly  felt  below  the  symphysis  pubis;  and 
if  the  head  be  not  unusually  large;  the  pelvis  a  little  contracted; 
or  the  sacrum  too  straight;  the  centre  of  the  occipital  bone  will 
be  found  to  correspond  with  the  symphysis  pubis:  but  if  either  of 
these  circumstances  obtain,  it  will  be  perceived  to  answer  to  the 
leg  of  the  left  pubis,  and  ischium.  At  this  moment,  the  chin  of 
the  child,  which  had  hitherto  been  placed  on  its  breast,  begins 
to  depart  from  it;  the  vertex  advances  and  separates  the  external 
parts,  by  engaging  under  the  pubes,  and  rises  up  towards  the 
mons  veneris;  the  inferior  edge  of  the  symphysis  pubis  answers 
as  a  kind  of  axis  for  the  head  to  turn  on ;  in  doing  this,  the  head 
describes  about  a  quarter  of  a  circle  backward.     For  the  head,  in 

*  It  must  be  borne  in  mind,  that  the  head  of  the  child  never  engages  in  tlie 
superior  strait,  in  a  perpendicular  or  vertical  position;  for  this  cannot  happen, 
and  coincide  with  the  direction  of  the  opening  of  tliis  strait,  since  this  is  at  an 
angle  of  about  30°,  and  consequently,  the  head  must  enter  this  opening  at  the 
same  angle. 


SECOND  AND  THIRD  POSITIONS.  227 

issuing  from  the  pelvis,  obliges  the  chin  to  describe  an  extensive 
curve;  passing  successively  over  the  whole  of  the  central  line  of 
the  sacrum,  coccyx,  and  perinaeum;  while  the  vertex  itself  passes 
through  but  a  small  space.  So  soon  as  the  head  has  escaped 
through  the  external  machinery,  the  face  is  found  to  turn  almost 
always  towards  the  right  thigh. 

629.  The  shoulders  are  now  to  deliver  themselves;  Avhlch 
they  do  in  the  following  order — the  right  shoulder  advances  to- 
wards the  pubes,  while  the  left  is  placed  before  the  sacrum, 
and  is  by  the  force  of  the  pains  made  to  descend  lower  and  lower 
until  its  point  issues  from  the  bottom  of  the  vulva,  while  the  right 
is  freeing  itself  from  under  the  pubes.  When  the  shoulders  are 
delivered,  the  rest  of  the  body  follows  immediately. 

630.  "By  following,"  says  Baudelocque,  "  step  by  step  the 
course  I  have  just  traced  from  observation,  it  will  appear,  1.  That 
at  all  periods  of  labour,  the  head  presents  its  smallest  diameters 
to  the  pelvis,  and  that  it  passes  through  it,  presenting  only  its 
smallest  circumference.  2.  That  it  executes  three  different  mo- 
tions in  its  passage;  that  of  flexion  forward,  in  the  first  period; 
the  pivot-like  or  rotatory  motion  in  the  second;  and,  lastly,  that 
of  flexion  backward,  at  the  time  it  disengages  from  under  the 
pubes."     Vol.  I.  p.  362.     See  Plate  VI. 

Sect.  II. —  Of  the  Character  and  Mechanism  of  the  Second 
Position. 

631.  The  mechanism  of  the  second  position  is  precisely  the 
same  as  that  of  the  first,  if  we  change  the  position  of  the  vertex, 
and  place  it  at  the  right  acetabulum,  instead  of  the  left.  In  con- 
sequence of  the  right  lateral  obliquity  of  the  uterus  prevailing  so 
often,  and  the  rectum  not  passing  immediately  down  the  centre 
of  the  sacrum,  and  being  occasionally  impacted  with  hardened 
fgeces,  this  presentation  is  not  quite  as  favourable  as  the  first — 
but  we  rarely  find  in  practice  any  essential  difference  between 
them ;  for  w^e  may  always  controul  the  obliquity  of  the  uterus,  by 
placing  the  woman  upon  her  left  side;  and  can  empty  the  rectum 
by  an  injection,  as  is  my  uniform  practice,  when  I  find  things  thus 
situated.     See  Plate  VII. 

Sect.  III. — Character  and  Mechanism  of  the  Third  Position. 

632.  In  this  presentation,  the  posterior  fontanelle  answers  to 


228  FOURTH  POSITION. 

the  symphysis  pubis,  and  the  anterior  to  the  projection  of  the 
sacrum;  and  where  a  proper  relation  exists  between  the  head 
and  pelvis,  this  presentation  is  not  attended  with  more  difficulty 
perhaps  than  the  two  former  positions;  provided  neither  the 
right,  nor  the  left  lateral  obliquities,  carry  the  head  from  the 
centre  of  the  pelvis;  for  the  vertex  will  be  found  to  descend  be-r 
hind  the  symphysis  pubis,  while  the  chin  will  mount  upwards, 
and  place  itself  against  the  breast,  as  in  the  former  cases;  in  con- 
sequence of  this,  the  head  will  only  present  its  perpendicular 
diameter  to  the  small  diameter  of  the  upper  strait;  and  when 
the  vertex  has  arrived  at  the  bottom  of  the  pelvis,  the  occipital 
bone  will  be  found  to  offer  itself  to  the  arch  of  the  pubes,  and 
will  pass  through  the  external  parts  as  in  the  first  and  second 
presentations.  The  shoulders  will  now  present,  but  there  will 
be  no  certainty,  whether  it  will  be  the  right,  or  the  left.  See 
Plate  VIII. 

Sect.  IV. — Character  and  Mechanism  of  the  Fourth  Position. 

633.  This  position  is  by  no  means  so  favourable,  as  either  of 
those  just  described;  for  the  forehead  must  come  under  the  arch 
of  the  pubes,  in  consequence  of  the  anterior  fontanelle  being  to  the 
left  acetabulum,  and  the  posterior  to  the  right  sacro-iliac  symphy- 
sis. In  order  that  the  head  may  pass  on,  it  must  descend  until  a 
portion  of  the  right  parietal  bone  rests  upon  the  inferior  part  of 
the  sacrum;  when  there,  the  pivot-like  motion  mentioned  (627) 
in  the  other  presentations  must  take  place,  if  everything  go  on 
well,  and  by  the  same  mechanism.  This  motion,  however,  in  this 
instance,  is  such,  as  to  place  the  forehead  under  the  arch  of  the 
pubes,  by  sliding  along  the  left  side  ofthe  pelvis. 

634.  In  consequence  of  the  forehead  being  placed  under  the 
arch  of  the  pubes,  the  anterior  fontanelle  will  be  found  in  the 
middle  ofthe  arch,  and  the  posterior  above  the  point  ofthe  sacrum. 
The  head  being  urged  by  the  pains,  descends  still  lower  in  the 
pelvis,  and  makes  the  posterior  fontanelle  pass  over  the  coccyx 
and  perinoeum,  while  the  anterior  and  forehead,  are  confined,  as 
it  were,  to  the  arch  of  the  pubes.  Indeed,  it  mounts  a  little  be- 
hind the  symphysis;  as  the  anterior  part  of  the  head,  has  not  the 
same  relation  to  the  arch,  as  the  occipital  region  ;  therefore,  the 
anterior  fontanelle  becomes  almost  stationary,  while  the  posterior 
continues  to  advance,  and  stretch  the  perinseum,  which  presently 


FOURTH  POSITION.  229 

slips  over  the  occiput,  and  retires  with  its  edge  to  the  child's 
neck,  and,  like  the  same  part  when  under  the  arch  of  the  pubes 
in  the  former  presentations,  becomes  the  centre  of  motion,  and 
permits  the  occipital  region  to  turn  backward  towards  the  anus  of 
the  mother ;  at  the  same  time  the  face  disengages  itself  from  un- 
der the  pubes.  In  this  instance,  as  in  the  former,  the  chin  is 
made  to  describe  a  curved  line,  but  in  a  contrary  direction. 

635.  So  soon  as  the  chin  is  liberated  from  the  arch  of  the  pubes, 
and  appears  without,  the  face  of  the  child,  by  half  a  turn,  places 
itself  towards  the  left  thigh  of  the  mother;  at  the  same  time  the 
shoulders  descend,  and  the  left  is  found  under  the  pubes,  while 
the  right  moves  towards  the  sacrum,  and  is  first  disengaged  from 
the  vulva.     See  Plate  IX. 

636.  This  species  of  labour  is  necessarily  more  difficult,  and 
painful  than  those  we  have  just  considered;  and  it  oftentimes 
becomes  extremely  so,  if  the  head  be  either  relatively  or  posi- 
tively large  for  the  pelvis.  It  requires,  in  some  instances,  many 
hours  to  accomplish  a  labour,  that  would  have  been  speedily  ter- 
minated, had  either  of  the  two  first  been  the  presentation;  more 
especially,  if  resisting  soft  parts  should  be  added,  to  the  other  diffi- 
culty. Baudelocque  thinks  that  the  right  lateral  obliquity  would 
also  increase  the  evil  of  this  presentation;  but  this  I  believe  can 
be  surmounted,  by  placing  the  woman  upon  her  left  side.  This 
labour  is  always  of  longer  duration,  than  where  the  vertex  pre- 
sents; and  of  course  the  woman's  sufferings  are  increased,  in  pro- 
portion to  the  duration;  now,  as  we  almost  always  have  it  in  our 
power  to  reduce  both  this,  and  the  fifth,  one  to  the  second,  and  the 
other  to  the  first,  we  should  always  do  it,  when  nature  does  not 
do  it  for  us.  Nor  is  this  change  of  position  of  the  head,  an  ope- 
ration of  the  slightest  difficulty  to  the  accoucheur,  nor  does  it  cause 
the  smallest  pain  to  the  patient;  provided,  advantage  be  taken 
of  the  proper  conditions  of  the  uterus,  and  head  of  the  child,  and 
the  state  of  the  labour.  For  the  uterus  must  be  well  dilated,  the 
membranes  ruptured,  the  head  occupying  the  lower  strait,  and 
the  labour  active.  When  these  pre-requisites  obtain,  the  point  of 
the  fore-finger  must  be  placed  against  the  edge  of  the  sagital  su- 
ture, either  before  or  behind  the  anterior  fontanelle ;  and  in  the 
absence  of  pain,  this  part  must  be  pressed  towards  the  left  sacro- 
iliac symphasis,  and  maintained  there  during  the  subsequent  con- 
traction of  the  uterus.  Should  this  first  attempt  fail  in  changing 
the  position  of  the  head,  by  bringing  the  posterior  fontanelle  to  the 


230  FOURTH  POSITION. 

right  acetabulum,  the  attempt  must  be  repeated  again  and  again 
until  it  succeed;  which  it  will  almost  constantly  do. 

637.  I  consider  a  perfect  knowledge  of  this  presentation,  (for  it 
is  far  from  being  unfrequent,)  a  matter  of  high  moment  to  the 
practitioner;  and  particularly  so  in  this  country,  where  the 
study  of  midwifery  engages  so  much  of  the  attention  of  the  medi- 
cal student,  and  where  every  one  almost,  who  enters  upon  the 
practice  of  physic,  must  also  become  a  practitioner  of  obstetrics. 
So  positive  an  advantage  does  a  knowledge  of  this  presentation, 
and  the  mode  of  reducing  it,  give  one  practitioner  over  the  one 
who  may  be  ignorant  of  it,  that  it  enables  the  first  to  terminate  a 
labour  in  as  many  minutes,  as  the  other  might  be  hours. 

638.  So  decidedly  useful  is  the  knowledge  of  the  fourth  and 
fifth  presentations,  to  the  patient,  that  I  hold  that  man  incompe- 
tent to  practise  midwifery,  in  its  best  manner,  v/ho  cannot  de- 
tect, and  change  this  mal-position  of  the  head,  and  thus  abridge 
sometimes,  by  several  hours,  the  misery  and  pain  of  his  patient. 
I  therefore  hold  Dr.  Denman's*  advice  as  unfriendly  to  the  im- 
provement of  midwifery,  when  he  says,  "  When  the  membranes 
break,  if  the  os  uteri  be  fully  dilated,  the  child,  though  resting  at 
the  superior  aperture  of  the  pelvis,  either  sinks  by  its  own  gravi- 
ty, if  the  woman  be  in  an  erect  position,t  or  is  propelled  by  the 
continuance  of  the  same  pain  by  which  they  were  broken;  or,  af- 
ter a  short  respite,  the  action  of  the  uterus  returns,  and  the 
head  of  the  child  is  brought  so  low  in  the  pelvis,  as  to  press  upon 
the  external  parts;  properly  speaking,  upon  the  internal  surface 
of  the  perineum.  In  its  passage  through  the  pelvis,  the  head  of 
the  child  which,  at  the  superior  aperture  was  placed  with  one 
ear  to  the  ossa  pubis,  and  the  other  to  the  sacrum,  or  with  dif- 
ferent degrees  of  diagonal  direction,  undergoes  various  changes 
of  position,  by  which  it  is  adapted  to  the  form  of  each  part  of  the 
pelvis,  with  more  or  less  readiness,  according  to  its  size,  the  de- 
gree of  its  ossification,  and  the  force  of  the  pains.  With  all  these 
changes,  whether  produced  easily  or  tediously ,  in  one  or  many 
hours,  the  practitioner  should  on  no  account  interfere,  pro- 
vided the  labour  be  naiuraV^ 

*  Introduction,  Francis's  ed.  p.  282. 

+  Dr.  Denman  is  certainly  wrong',  when  he  supposes  that  the  child's  head 
will  sink  into  the  cavity  of  the  pelvis  by  its  own  gravity,  if  the  woman  be  stand. 
ing;  for,  when  she  is  erect,  the  head  finds  a  resting-place  on  the  anterior  mar- 
gin of  the  pelvis.     See  note  to  par.  627. 


FOURTH  POSITION.  231 

639.  Agreeably  to  this  advice,  we  are  not  to  interfere,  though 
the  head  present  in  either  tiie  fourth,  or  the  fifth  presentation; 
though  we  can,  by  an  opportune,  and  well-directed  force,  shorten 
the  woman's  sufi'erings  perhaps  many  hours;  especially  with  a 
first  child;  and  this  without  offering  the  slightest  violence  to  either 
mother  or  child.  Nature,  indeed,  sometimes,  though  not  suffi- 
ciently often,  operates  this  change  herself;  and  is  this  not  suffi- 
cient to  warrant  the  practitioner  to  imitate  her?  I  have  always 
done  this  since  I  first  became  sensible  of  its  advantages;  a  period 
now,  of  more  than  thirty  years,  unless  the  labour  has  been  too 
far  advanced  to  permit  a  change,  which  has  not  been  oftener 
than  three  times,  during  the  whole  of  the  period  stated.  In 
doing  this,  I  am  well  assured  that  I  was  but  performing  a  duty 
by  shortening,  as  well  as  moderating  the  woman's  sufferings — 
indeed,  so  convinced  am  I  of  the  propriety  and  utility  of  this 
*'  interference,"  that  I  should  hold  myself  culpable  did  I  neglect 
to  take  advantage  of  this  important  hint  of  nature. 

640.  The  propriety  of  changing  this  and  the  fifth  position  of 
the  head  cannot  be  questioned,  when  a  moment's- reflection  is  be- 
stowed upon  its  mechanism.  Yet  neither  Dr.  Denman,  nor  any 
of  his  friends,  appear  to  have  been  acquainted  with  the  proper 
mode  of  treating  these  cases.  It  is  truly  a  matter  of  surprise, 
that  they  should  have  been  unwilling  to  receive  information 
from  their  neighbours  upon  this  important  point  of  obstetric  prac- 
tice; for  they  certainly  were  in  possession  of  the  works  of 
Baudelocque,*  in  which  he  so  scientifically  and  successfully  treats 
of  this  subject.  It  is  tru£  that  Dr.  John  Clarke,  about  the  year 
1800,  seems  to  have  accidentally  caught  a  glimpse  of  the 
proper  manner  of  conducting  such  labours.  I  say  a  "  glimpse;" 
for  it  was  but  little  more,  as  he  confounds  the  fourth  and  fifth  pre- 
sentations with  the  sixth;  and  does  not  appear  to  think  or  to 
know  there  is  a  difference  in  their  natures  or  mechanism.  He 
confesses  that  "chance  first  led  him  to  the  knowledge  of  the  fact, 
that  in  some  cases  this  position  of  the  head  can  be  remedied 
without  subjecting  the  mother  to  any  additional  pain,  or  the 
child  to  any  kind  of  danger."  He  adds,  '<that  every  body 
who  has  been  engaged  in  the  practice  of  midwifery  knows,  that 
if  in  labour  the  face  of  the  child  lies  towards  the  symphysis 
pubis,  that  considerable  difficulty  is  thereby  frequently  occasion- 
ed."    Now  this  situation  of  the  face  constitutes,  properly  speak- 

*  Baudelocque  Was  translated  by  Heatli,  and  published  in  1790. 


232  FOURTH  POSITION. 

ing,  the  sixth  presentation,  which  certainly  could  not  be  intend- 
ed, since  he  speaks  of  this  position  as  one  of  frequent  occurrence, 
a  circumstance  denied  by  all  the  best  writers  upon  the  subject. 
In  "  Phospice  de  la  maternity,"  the  sixth  presentation  is  acknow- 
ledo-ed  to  have  occurred  but  once  in  twelve  thousand  one  hun- 
dred and  eighty-three  labours. 

641.  It  is  farther  evident  that  he  confounds  these  very  different 
presentations,  v/hen  he  says,  "  if  on  examination,  the  anterior 

fontanelU  be  felt,  and  the  sagital  suture  be  found  running 
from  it  towards  one  of  the  sacro-iliac  joints,  or  directly  to- 
wards the  concavity  of  the  os  sacrum,  there  remains  no  doubt 
that  the  face  will  be  born  towards  the  symphysis  pubis." 

642.  Now  the  direction  of  the  sagital  suture,  constitute  two 
essentially  different  presentations,  and  requires  very  different 
modes  of  treatment,  as  it  may  be  towards  the  sacrum,  or  one  of 
the  sacro-iliac  junctions.  Moreover  the  fourth  and  fifth  presen- 
tations are  of  comparatively  frequent  occurrence ;  while  the 
sixth,  as  we  have  just  stated,  is  extremely  rare.  Agreeably 
to  the  same  returns  above  mentioned,  in  the  same  number  of 
labours,  the  fourth  occurred  forty  times,  and  the  fifth  two-and- 
twenty. 

643.  Again,  Dr.  Clarke  is  not  exactly  right,  when  he  says, 
<'  if  the  anterior  fontanelle  be  felt,  and  the  sagital  suture  be 
found  running  from  it,  (the  symphysis  pubis,)  towards  one  of  the 
sacro-iliac  joints,  or  directly  backwards  to  the  concavity  of  the  os 
sacrum,  there  remains  no  doubt  but  that  the  face  will  be  born  to- 
wards the  symphysis  pubis;"  for  the  fourth  and  fifth  presenta- 
tions sometimes  reduce  themselves  to  the  first  and  second;  a  cir- 
cumstance which  cannot  possibly  occur  in  the  sixth. 

644.  Again,  Dr.  Clarke  is  but  partially  right  when  he  asserts 
<'it  is  unnecessary  to  observe  that  this  alteration  will  be  more 
easily  produced,  when  the  face  lies  towards  the  groin,  than  when 
the  sagital  suture  runs  directly  backwards  towards  the  sacrum, 
but  even  in  this  case  the  change  may  be  effected  with  much 
more  facility  than  I  beforehand  supposed  it  possible ;"  for  we 
must  declare  that  neither  Dr.  Clarke,  nor  any  other  man,  ever 
succeeded  in  bringing  the  vertex  under  the  arch  of  the  pubis, 
when  the  sagital  suture  ran  directly  from  the  symphysis  pubis  to- 
wards the  sacrum,  as  in  the  case  of  the  sixth  presentation.  See 
Plates  VIII.,  IX.,  X.  and  also  the  account  of  the  management  of 
the  sixth  presentation. 


FIFTH  AND  SIXTH  PRESENTATION.  233 

Sect.  Y .—Character,  and  Mechanism,  of  the  Fifth  Presen- 
tation. 

645.  All  the  relations  of  the  child's  head,  and  that  of  the  pelvis, 
are  the  same  in  this,  as  in  the  one  just  spoken  of;  we  have  only 
to  imagine  the  anterior  fontanelle  to  the  right  acetabulum,  and 
recollect  the  mechanism  of  the  fourth  vertex  presentation,  to  be 
in  possession  of  this;  but  in  this  presentation  a  little  more  difficul- 
ty may  be  experienced  than  in  the  fourth,  owing  to  the  contin- 
gencies, (636)  which  may  make  the  second,  not  so  favourable  as 
the  first,  as  -has  been  already  stated.  When  the  head  escapes 
from  the  vulva,  the  face  will  turn  towards  the  right  groin.  Na- 
ture sometimes  reduces  this  case  to  a  first  presentation,  and  thus 
teaches  us  a  salutary  lesson.     See  Plate  IX. 

Sect.  VI. — Character,  and  Mechanism,  of  the  Sixth  Presen- 
tation. 

646.  This  presentation  is  of  most  rare  occurrence;  having 
met  with  but  three  instances  of  it;  two  of  which  were  twin 
cases ;  but  from  the  smallness  of  their  heads,  they  created  no  de- 
lay in  the  labour.  They  happened,  in  both  cases,  to  be  with  wo- 
men who  had  previously  borne  children.  The  third  instance  was 
under  the  care  of  a  midwife;  but  as  it  was  one  of  much 
longer  duration  than  the  woman  had  before  experienced,  and  as 
the  pains  were  very  frequent,  severe,  and  ineffectual,  my  advice 
was  asked.  I  found  the  head  still  at  the  superior  strait;  the  an- 
terior fontanelle  was  immediately  behind  the  symphysis  pubis; 
the  scalp  was  very  tumid  and  pushed  forward,  and  downward. 
I  waited  for  the  efiects  of  two  or  three  pains,  which  I  found  did 
nothing  more  than  to  push  the  swoln  scalp  a  little  lower  in  the 
pelvis,  but  without  advancing  the  head,  though  the  efforts  were 
very  strong.  I  passed  up  my  hand  and  turned  the  anterior  fon- 
tanelle towards  one  of  the  acetabula,  and  then  committed  the 
case  to  the  natural  powers;  which  pretty  soon  accomplished  the 
delivery. 

647.  The  character  of  this  presentation  is  exactly  the  reverse 
of  the  third;  that  is,  the  anterior  fontanelle  is  placed  behind  the 
symphysis  pubis,  and  the  posterior  before  the  sacrum.  There  are 
two  circumstances  connected  with  this  position,  which  render  it 
less  favourable  than  either  of  the  other  positions:  1st.  The  great 
diameter  of  the  head,  being  parallel  to  the  small  diameter  of  the 
30 


234  SIXTH  PRESENTATION. 

upper  strait.  2d.  The  forehead  being  under  the  absolute  neces- 
sity of  coming  under  the  arch  of  the  pubes;  for  in  this  presenta- 
tion, we  cannot,  as  in  the  fourth  and  fifth,  change  it  to  the  se- 
cond or  first,  as  I  shall  have  occasion  to  observe  elsewhere.  See 
Plate  X. 

648.  The  occiput,  in  this  presentation,  descends  along,  and 
before  the  sacrum,  until  it  arrives  at  the  inferior  part  of  the  os 
externum;  pressing  the  perinseum  before  it,  until  it  escapes 
through  the  externaf  parts;  it  then  turns  immediately  backward, 
as  described  in  the  fourth,  and  fifth  species,  of  vertex  presenta- 
tion. 

649.  It  would  be  easy  to  multiply  the  presentations  of  the 
head,  as  Baudelocque  justly  observes,  were  it  of  any  practical  im- 
portance ;  but  as  this  is  not  the  case,  it  would  only  tend  to  em- 
barrass, rather  than  answer  any  profitable  purpose.  ISIathemati- 
cal  precision  is  not  required  in  such  cases;  especially,  as  the  me- 
chanism of  the  labour  is  not  altered ;  for,  when  the  posterior  fon- 
tanelle  is  at  all  in  advance  of  the  sacro-iliac  junction,  either  right 
or  left,  it  will  almost  always  eventually  place  itself  under  the 
arch  of  the  pubes,  and  this  is  all  that  is  necessary. 


I 


PART  II. 


OF  LABOUES,  IN  WHICH  THE  CHILD  PRESENTS   THE   VERTEX, 
BUT  RENDERED  DIFFICULT  OR  PRETERNATURAL. 


650.  I  NOW  commence  agreeably  to  the  plan  proposed,  with 
the  consideration  of  the  causes  which  may  render  a  natural  labour 
preternatural,  or  difficult,  but  which  can  be  terminated  by  the 
hand  alone;  as  well  as  the  mode  of  operating  in  such  cases.  I 
shall  exclude  from  this  division,  such  causes,  which  of  themselves 
would  render  the  use  of  instruments  necessary  or  proper,  they 
being  to  be  consisidered  under  another  head. 


CHAPTER  XVII. 

CAUSES  OF  PRETERNATURAL  LABOURS. 

651.  Many  causes  may  render  a  natural  labour,  a  preternatu- 
ral one ;  or  it  may  be  essentially  bad  from  the  beginning,  owing 
to  the  untoward  situation  of  the  child.  They  may,  therefore,  be 
both  accidental,  and  unavoidable.  Among  the  causes  we  may 
enumerate:  1st.  Flooding ;  2d.  Convulsions  ;  3d.  Syncope;  4th. 
Hernia ;  5th.  Obliquity  of  the  uterus ;  6th.  Partial  contractions  of 
the  uterus  ;  7th.  Compound  pregnancy;  8th.  Descent  of  the 
cord  ;  9th.  Too  short  a  cord  ;  10th.  Bad  position  of  the  head  ; 
11th.  Exhaustion;  12th.  Hsemorrhages  from  the  lungs  or  other 
organs. 

652.  A  labour  may  commence  with  every  prospect  of  being 
speedily  and  successfully  terminated;  but,  after  a  continuance  for 
a  longer  or  a  shorter  time,  with  the  fairest  promise,  the  patient 
may  be  assailed  by  some  accident,  which  puts  in  jeopardy  her 
life,  or  that  of  the  child,  or  both,  and  from  which  nothing  can 
save  them,  but  the  well-directed  and  timely  interference  of  art. 


236  FLOODING. 

One  of  the  most  common,  and  at  the  same  time,  one  of  the  most 
alarming,  is 

Sect.  I. — 1.  Flooding. 

653.  In  treating  of  flooding  in  this  place,  we  shall  confine  our 
considerations  to  the  subject  in  question  ;  or,  in  other  words,  as 
an  indication  in  a  natural  labour  ;  and  where  that  indication 
points  out  no  other  remedy  than  delivery  by  turning,  or  other 
manual  interference.  A  flooding  may  take  place  after  labour  has 
commenced,  under  two  different  conditions  of  the  os  uteri:  first, 
where  it  is  but  partially  dilated,  but  rigid  ;  second,  vvhere  it  is 
dilated,  or  easily  dilatable. 

654.  These  two  conditions  are  by  no  means  indifferent;  they 
are  of  great  practical  importance,  and  should  never  be  con- 
founded. 

655.  Should  hBemorrhage  take  place  in  the  early  part  of  la- 
bour, and  before  the  os  uteri  is  sufficiently  well  opened  for  the 
purposes  of  delivery,  we  should  not  think  of  immediate  delivery ; 
as  there  can  be  no  absolute  necessity  for  hasty  or  rash  interfer- 
ence while  the  uterus  is  in  the  condition  here  spoken  of,  it  would 
be  the  height  of  imprudence  to  enter  the  uterus  by  force,  for  the 
purpose  of  turning.  Indeed  Baudelocque*  says,  and  I  fully  con- 
cur with  him,  "  Whatever  abundance  of  blood  the  woman  may 
lose,  nothing  could  justify  the  conduct  of  the  accoucheur  who 
would  persist  in  endeavouring  to  deliver  without  delay;"  for  it 
would  only  be  creating  new  difficulties,  instead  of  relieving  the 
existing  one. 

656.  The  mode  of  proceeding  in  such  cases,  is,  first,  to  attempt 
moderating  the  discharge,  by  rest,  a  horizontal  posture,  by  blood- 
letting if  the  pulse  be  full,  by  the  exhibition  of  pretty  large  doses 
of  the  acetate  of  lead,  by  cold  applications,  but  above  all,  by  the 
tampon.t  Second:  By  promoting  the  contraction  of  the  uterus, 
should  the  above  means  fail,  by  rupturing  the  membranes  as  di- 
rected by  Puzos;  but  under  the  restriction  suggested,  when  treat- 

•  System,  Vol.  II.  par.  1809. 

I  In  using  the  tampon,  it  is  never  necessary  to  stop  the  mouth  of  the  uterus, 
as  recommended  by  Leroux,  Baudelocque,  and  others ;  it  is  every  way  suffi- 
cient/ that  the  vagina  be  occupied  by  a  sponge  of  a  sufficient  size — tlie  mouth 
of  the  uterus  becomes  filled  pretty  quickly  by  a  coagulum,  if  the  tampon  is  as 
successful  as  might  be  anticipated. 


FLOODING.  237 

ing  on  this  point.     See  chapter  on  Uterine  Haemorrhage,  "  Dis- 
eases of  Females." 

657.  Should  the  haemorrhage  take  place  when  the  os  uteri  is 
well  dilated,  or  easily  dilatable,  vve  should  proceed  to  turning; 
provided,  the  rupturing  of  the  membranes  have  not  abated  the  dis- 
charge. Or  should  the  flooding  have  commenced  after  the  waters 
have  been  evacuated,  if  the  quantity  threaten  the  life  of  the  mo- 
ther or  child,  and  the  child's  head  is  at  or  near  the  upper  strait; 
and  provided,  also,  the  natural  powers  of  delivery  do  not  advance 
the  head  sufficiently  fast  to  give  a  promise  of  a  speedy  delivery.* 
Should  the  signs  which  would  render  turning  the  best  mode  of 
terminating  the  delivery  not  be  present,  vve  must  have  recourse 
to  the  forceps.t     The  mode  of  operating  with  them  in  particular 

•  It  has  been  advised  by  some,  when  we  have  so  far  succeeded  in  turning, 
as  to  bring  the  feet  to  the  passage,  that  we  should  wait  some  time,  before  we 
finish  the  operation.  Dr.  Davis  is  the  latest  authority  for  this  practice:  he  ob- 
serves "It  is  a  fact,  which  it  must  have  often  occurred  to  practitioners  of  expe- 
rience to  observe,  that  the  operation  of  turning  is  for  the  most  part  immediate- 
ly followed  by  a  cessation  of  the  haemorrhage.  The  change  thus  effected  on  the 
situation  of  the  child  in  utero  being  made,  it  is  generally  both  unnecessary  and 
improper  to  proceed  hastily  to  complete  the  delivery;  which  therefore  it  would 
be  often  much  better  to  delay  for  an  hour  or  two,  to  wait  a  favourable  disposi- 
tion of  the  soft  parts,  than  to  undertake  it  immediately  after  having  brought 
down  the  feet  into  the  birth."     {Elem.  Oper.  Mid  p.  160.) 

I  cannot  by  any  means  agree  to  this  advice;  and  for  the  following  reasons: — 
1st.  Because  I  have  never  recognized  as  a  fact,  that "  the  operation  of  tiu-ning 
is  for  the  most  part  immediately  followed  by  a  cessation  of  the  hsemorrhagCi" 
that  is,  the  mere  change  of  position  of  the  child;  for  there  can  be  no  possible 
reason  why  it  should  be  so,  unless  it  give  greater  opportunity  for  the  tonic 
power  of  the  uterus  to  exert  itself;  and  this  can  be  as  certainly  effected  by  sim- 
ply rupturing  the  membranes.  2d.  In  an  hsemori'hage  of  such  extent  as  would 
require  turning  as  a  remedy,  the  patient  can  never  be  considered  safe  until  the 
uterus  is  empty,  that  the  tonic  powers  of  this  organ  can  effectually  arrest  the 
discharge.  3d.  After  we  have  been  forced  to  enter  the  uterus,  I  beUeve  it  to 
be  the  soundest  practice  to  finish  the  delivery,  slowly  and  carefully;  especially, 
as  I  never  attempt  to  turn  in  such  cases,  until  there  is  "  a  favourable  disposition 
of  the  soft  parts"  to  permit  dehvery;  as  I  am  certain,  it  never  can  be  absolute- 
ly necessary  to  interfere  until  then.  {See  Chap,  on  Uterine  Hemorrhage;  Dis- 
eases of  Females,  by  the  Author. ) 

•j-  Dr.  Davis  intimates,  rather  than  enforces  the  use  of  the  forceps,  under  cir- 
cumstances, which  my  reasoning  upon  the  subject,  as  well  as  my  experience, 
leads  me  to  fear;  namely,  where  the  head  is  high  in  the  pelvis.  He  says,  "In 
cases  of  haemorrhage  occurring  at  an  early  period  of  labour,  there  could  indeed 
be  no  impropriety  in  having  recourse  to  the  use  of  forceps  of  more  than  ordina- 
ry length,  provided  the  state  of  the  orifice  of  the  uterus  as  to  dilatation,  was  such 
as  to  be  compatible  with  the  safe  employment  of  any  kind  of  instrument  on  the 
principle  of  the  forceps.     In  some  few  cases  of  this  description,  the  fcetal  head 


238  CONVULSIONS. SYNCOPES. 

presentations,  will  be  pointed  out  under  each  respective  case. 
Sec  Chapter  on  Forceps,  &c. 

Sect.  II. — 2.  Convulsions. 

658.  This  alarming  disease  may  attack  a  woman  after  labour 
has  commenced,  and  under  precisely  the  same  conditions  of  the 
uterus  as  I  have  stated  above.  (655)  Should  they  attack  while 
the  uterus  is  but  little  dilated,  and  rigid,  we  should  not  think  of 
attempting  the  delivery  of  the  child;  as  it  would  be  as  mischiev- 
ous in  this,  as  in  the  former  case.  Our  first  attempt  should  be  to 
moderate  the  force,  and  diminish  the  frequency  of  the  convulsions, 
by  blood-letting,  and  the  other  means  recommended  in  the  chap- 
ter upon  this  subject,  until  the  uterus  has  become  softened,  or 
dilated;  then,  provided  the  natural  powers  be  not  sufficiently  ac- 
tive, or  competent  to  the  finishing  of  the  labour,  we  should 
proceed  to  turn. 

659.  Should  the  uterus,  however,  be  dilated,  or  easily  dilata- 
ble; and  the  convulsions  threatening;  especially,  if  the  pains  are 
not  of  sufficient  force  or  efficacy;  w^e  should  immediately  after  a 
copious  bleeding,  proceed  to  the  operation  of  turning,  with  a  view 
to  diminish  the  injurious  tendency  of  the  convulsions  upon  the 
head.  But  should  the  waters  be  long  drained  off,  and  the  head 
low  in  the  pelvis;  and  invariably,  should  it  have  escaped  from  the 
mouth  of  the  uterus,  the  forceps  are  exclusively  indicated.  See 
Chapter  on  Puerperal  Convulsions. 

Sect.  III. — 3.  Syncojjes. 

660.  I  have  seen  several  instances  where  the  pains  of  labour 
were  regularly  followed  by  syncope.  In  these  cases,  this  condi- 
tion of  the  system  did  not  seem  to  interrupt  the  progress  of  the 
labour  in  the  slightest  degree;  this  affection  was  constitutional, 
and  such  as  would  follow,  in  these  patients,  from  any  great  ex- 
citement or  alarm;  or  from  pain  or  temporary  exhaustion. 

661.  M.  Travers  says,  "a  person  suffering  acute  pain,  is  in  no 

being-  only  about  to  engage  at  the  brim  of  the  pelvis,  there  might  occasionally 
be  some  difficu]ty  in  determining  on  the  choice  to  be  made  between  an  opera- 
tion with  the  forceps  and  that  of  turning." 

Now,  in  my  estimation,  there  can  be  no  hesitation  about  the  choice  of  means 
— the  forceps  must  not  be  thought  of,  in  this  situation  of  the  head;  turning,  is 
the  proper  remedy;  for  the  hemorrhage  will  itself  remove  tlie  only  difficulty 
in  this  case;  namely,  the  obstinate  contraction  of  tlie  uterus. 


SYNCOPES.  239 

danger  of  syncope."*  This  is  true  during  the  continuance  of 
pain,  for  the  most  part,  but  there  are  exceptions  ;  we  have  seen 
fainting  take  place  during  the  extraction  of  a  tooth,  and  during 
the  cutting  in  a  severe  operation.  But  during  labour  we  have 
never  known  syncope  to  take  place  during  the  painful  contrac- 
tion of  the  uterus,  though  it  may  quickly  follow  the  cessation. 
This,  as  we  have  observed,  appears  to  be  owing  to  some  peculi- 
arity of  the  nervous  system,  and  does  not  interrupt  the  return  of 
subsequent  contractions. 

662.  In  cases  like  those  just  mentioned,  we  never  think  of  in- 
terfering with  the  natural  progress  of  labour.  But  when  these 
faintings  take  place,  where  peculiarity  of  constitution  will  not  ac- 
count for  them;  where  they  are  attended  with  increasing  exhaus- 
tion: where  the  labour-pains  diminish  both  in  force  and  frequen- 
cy; where  faintings  become  more  permanent  in  their  duration; 
and  where  the  pulse  flags,  or  becomes  nearly  extinct,  it  behoves 
the  practitioner  to  discover,  if  possible,  the  cause,  and  as  quickly 
as  may  be,  to  remove  it. 

663.  Dr.  Davis,  (Elem.  of  Oper.  Mid.  p.' 171,)  relates  the  follow- 
ing very  interesting  case  of  syncope.  "A  poor  woman,  a  patient 
of  the  Royal  Maternity  Charity,  under  the  care  of  an  intelligent 
midwife,  after  having  been  in  labour  for  about  five  hours,  became 
suddenly  very  faint  upon  the  bursting  of  the  foetal  membranes, 
and  the  discharge  of  a  considerable  quantity  of  liquor  amnii, 
whilst,  being  supported  in  a  sitting  attitude  on  a  chamber  utensil, 
she  was  making  an  effort  to  respond  to  one  of  the  calls  of  nature. 
She  was  immediately  laid  down  in  a  horizontal  posture;  but  upon 
further  adjustment  of  her  person  and  bed-clothes,  she  was  found 
to  be  perfectly  dead. "  "  The  body  of  the  deceased  was  carefully 
inspected  on  the  following  day:  but  no  cause  could  be  discovered 
for  the  sudden  death." 

664.  An  internal  hemorrhage t  is  perhaps  the  most  frequent 
cause  of  this  alarming  condition;  when  it  proceeds  from  this  source, 
it  always  commences  gradually;  that  is,  the  debility  is  not  sud- 
denly induced;  nor  are  the  syncopes  at  first  profound;  but  both 
may  increase  in  proportion  to  the  extent  or  force  of  the  remote 

*  Constitutional  Irritation,  p.  268.  Am.  Ed. 

t  Baudelocque,  System,  par.  1113,  relates  a  case  of  syncop.e  from  a  very 
large  calculus  in  the  gall-bladder. 


240  SYNCOPES. 

cause.*  The  abdomen  is  observed  to  enlarge;  sometimes  there  is 
a  slight  external  hasmorrhage,  or  discharge  of  serum  a  little  tinged 
with  blood;  the  pains  slacken;  and  the  woman  becomes  exhausted. 

665.  In  cases  like  these,  there  appears  to  be  but  one  remedy; 
which  is  immediate  delivery  by  turning,  provided  the  uterus  be 
in  the  condition  already  sufficiently  often  indicated,  to  permit  this 
operation;  and  if  not,  I  am  pretty  certain  there  is  not  that  neces- 
sity for  instant  delivery,  that  would  put  at  defiance  the  rules  I 
have  endeavoured  to  inculcate  against  forcibly  entering  the  uterus 
for  any  purpose — for  it  must  be  recollected,  that  after  labour  has 
commenced,  and  made  some  little  progress,  and  especially  if  the 
woman  has  gone  to  the  full  period  of  utero-gestation,  the  disposi- 
tion to  syncope  is  oftentimes  favourable  to  the  dilatation  of  the  os 
uteri,  or  at  least  renders  it  so  pliant  as  to  be  penetrated  by  a  little 
force — when  this  is  so,  turning  is  the  remedy;  but  we  must  take 
care  to  secure  the  tonic  contraction  of  the  uterus,  before  we  at- 
tempt the  delivery  of  the  placenta. 

666.  Baudelocquet  relates  cases  of  concealed  hjemorrhage  which 
are  highly  interesting,  and  well  worth  consulting.  From  what  he 
relates  upon  this  subject,  it  would  appear  that  an  haemorrhage  of 
this  kind  may  take  place  long  before,  as  well  as  near  the  period 
of  nine  months;  and  that  the  immense  distention  which  the  uterus 
suffers  from  the  influent  blood,  provokes  it  to  contraction,  and 
brings  on  labour-pains.  But  as  the  cause  which  may  produce  in- 
dicative syncopes,  cannot  always  be  ascertained;  and  as  it  is  ration- 
al to  suppose  it  is  in  some  way  or  other  connected  with  labour;  it 
will  be  well,  under  proper  conditions  of  the  uterus,  to  turn,  and 
thus  remove  a  difficulty,  if  not  the  cause  of  the  faintings.  Should 
these  occur  when  labour  is  far  advanced,  or  when  turning  would 


*  I  was  called  to  a  poor  woman,  whom  I  found  dead  upon  my  arrival,  from 
this  kind  of  hemorrhage,  joined  to  an  external  one — but  as  the  latter  was  not 
sufficient  to  cause  death,  and  as  it  was  declai-ed  by  the  midwife,  and  the  wo- 
men who  were  present,  that  the  abdomen  was  enlarged  after  the  discharge  be- 
came apparent,  and  as  this  had  been  arrested  by  some  means  or  other,  I  sus- 
pected an  internal  h^emorrhage  to  be  the  cause  of  her  death.  Leave  was  ob- 
tained to  inspect  the  body,  and  my  suspicions  were  confirmed.  In  this  case 
the  h3emorrhage  took  place  some  hours  after  the  labour  had  begun ;  but  there 
was  a  suspension  of  pain  soon  after,  and  most  probably  at  the  time  the  haemor- 
rhage took  place,  as  the  woman  had  said  she  was  now  easy,  and  wished  to  go 
to  sleep. 

t  System,  par.  1081,  1083,  1084. 


HERNIA.  241 

be  improper,  the  forceps  must  be  used.*^     (See  chapter  on  For- 
ceps.) 

Sect.  IV. — 4.  Hernia. 

667.  Hernias  of  long  standing,  are  sometimes  in  danger  of  be- 
coming strangulated  from  the  excessive  force  of  labour — if  this 
take  place,  we  are  obliged  to  deliver  by  turning,  when  the  natu- 
ral powers  seem  to  be  too  tardy  for  the  situation  of  the  hernia — 
the  time  when  this  is  to  be  attempted,  as  regards  the  condition  of 
the  uterus,  has  been  already  pointed  out.  I  will,  however,  illus- 
trate this  by  the  recital  of  an  interesting  case.     Mrs. ,  had 

laboured  under  an  unreduced  umbilical  hernia,  for  eighteen  years; 
it  gave  her  trouble  whenever  she  neglected  her  bowels,  or  was 
imprudent  in  diet.  When  I  was  called  to  her,  she  was  in  labour 
with  her  tenth  child — she  was  a  very  corpulent  woman,  and 
always  suffered  from  a  great  anterior  obliquity  of  the  uterus;  her 
labours  were  wont  to  be  both  tedious  and  severe.  Upon  this  oc- 
casion, it  was  uncommonly  slow  and  painful;  much  uneasiness 
had  been  experienced  in  the  hernial  tumour  from  time  to  time 
during  the  whole  day,  but  towards  evening,  (about  twelve  hours 
after  her  labour  had  fairly  commenced,)  it  became  more  and  more 
severe,  particularly  after  each  pain — fearing  what  might  happen, 
I  had  ordered  her  a  full  dose  of  castor  oil,  in  the  early  part  of  the 
day  ;  and  this  was  followed  by  a  brisk  purgative  injection;  the 
latter  procured  a  copious  evacuation  of  faeces,  but  the  oil  had  no 
effect.  Vomiting  now  ensued;  this  was  followed  by  a  disposi- 
tion to  syncope,  and  other  alarming  symptoms,  arising,  as  I  sup- 
posed, from  a  disposition  in  the  hernial  contents,  to  become  stran- 
gulated. I  mentioned  my  opinion  with  candour  to  tlic  friends  of 
the  patient,  and  proposed  immediate  delivery  as  the  most  proba- 
ble means  of  preventing  farther  mischief,  though  I  confessed  J 
was  by  no  means  certain  it  would  be  absolutely  effectual.  Tiie 
OS  uteri  was  now  sufficiently  dilated,  to  permit  the  operation  with 
propriety;  the  membranes  were  entire,  and  everything  favoura- 
ble for  the  attempt.  The  patient  was  placed,  as  will  be  directed 
by  and  by;  the  hand  was  passed,  the  membranes  ruptured,  and 
the  turning  performed  in  the  course  of  a  few  minutes,  with  the 
most  entire  success;  the  placenta  was  delivered  in  due  time.     A 

*  I  have  already  remarked,  (659,)  that  turning  is  never  to  be  attempted, 
when  the  head  has  escaped  from  the  orifice  of  the  uterus. 
31 


242  OBLIQUITY  OF  THE  UTERUS. 

full  dose  of  laudanum  was  now  given;  the  vomiting  and  sickness 
of  stomach  were  immediately  relieved  by  the  delivery — less  pain 
was  experienced  in  the  tumour,  and  all  the  unpleasant  symptoms 
seemed  to  vanish,  after  a  copious  evacuation  from  the  bowels, 
procured,  doubtless  from  the  oil,  which  fortunately  had  only 
been  retarded,  and  not  interrupted  by  the  laudanum.  My  pa- 
tient's recovery  was  as  rapid  as  was  usual  with  her.  She  died 
about  twelve  years  after,  of  strangulated  hernia. 

668.  Should  the  symptoms  which  would  render  immediate 
delivery  necessary,  not  occur  until  the  head  is  low  in  the  pelvis, 
the  waters  long  drained  off,  or  the  head  arrested  by  bad  position, 
or  if  it  have  escaped  from  the  os  uteri,  the  forceps  are  exclu- 
sively indicated.  (See  Chapter  on  Forceps.) 

Sect.  V. — 5.    Obliquity  of  the  Uterus. 

669.  The  deviations  of  the  uterus,  under  the  name  of  obliqui- 
ties of  this  organ,  have  already  been  pretty  fully  treated  of— (see 
29S,  &c.)  but  it  very  rarely  happens  that  either  of  them  alone  is 
the  cause  of  a  preternatural  labour,  though  it  may  complicate  it 
very  disagreeably.*  I  have  but  once  found  it  necessary  to  turn 
for  this  cause;  and  this  was  in  a  very  small  woman,  with  rather 
a  contracted  pelvis,  who  laboured  under  the  most  extensive  ante- 
rior obliquity  I  ever  remember  to  have  seen.  She  was  placed 
upon  her  back,  with  her  shoulders  lower  than  her  hips;  the  belly 
was  supported  by  a  towel,  and  the  hands;  but  nothing  seemed 
sufficient  to  make  the  head  engage  in  the  pelvis.  The  pains  were 
extremely  severe,  and  very  frequent;  and  the  poor  creature  suf- 
fered for  many  hours  to  no  purpose.  Seeing  no  prospect  of  de- 
livery taking  place  from  the  exertion  of  the  natural  powers,  I 
thought  it  best,  after  due  consideration,  to  terminate  the  delivery 
by  turning— this  was  accordingly  done,  with  perfect  success. 

Sect.  VI. — 6.  Partial  Contractions  of  the  Uterus. 

670.  By  these,  we  are  to  understand  the  contractions  of  the 
external  or  inferior  edge  of  the  mouth  of  the  uterus,  as  well  as 
that  portion  which,  in  the  unimpregnated  state,  constitutes  the 
internal  edge,  or  orifice  of  this  organ,  round  the  neck  of  the  child  ; 
so  as  to  prevent  the  descent  of  the  shoulders.     The  first  of  these 

*  See  Baudelocque's  cases,  pai*.  298. 


PARTIAL  CONTRACTIONS  OP  THE  UTERUS.        243 

conditions  is  the  most  serious  in  its  consequences,  because,  it  is 
more  diflicult  to  remedy.  In  this  case,  the  head  of  the  child  has 
escaped  through  the  external  ring  which  constitutes  the  mouth  of 
the  uterus;  in  consequence  of  which  the  neck  of  the  uterus  re- 
tracts itself  behind  it,  and  being  no  longer  stretched  by  the  bulky 
part  of  the  head,  it  contracts;  and  this  so  strictly  sometimes,  as  to 
embrace  the  neck — when  this  takes  place,  the  shoulders  cannot 
pass  the  barrier  which  the  contracted  neck  offers,  and  they  are 
thereby  arrested;  as  their  form  is  but  ill-calculated  to  dilate  again 
the  mouth  of  the  uterus;  for  now,  it  can  only  be  opened  by  me- 
chanical means. 

671.  In  the  second  case,  the  head  remains  enveloped  in  the 
lower  portion  of  the  uterus,  (which  portion  in  the  linimpregnated 
state  constitutes  its  neck,)  wiiile  the  internal  edge  contracts 
round  the  neck  of  the  child,  but  not  so  strictly;  and  thus  is  offer- 
ed on  all  sides  an  inclined  plane  for  the  shoulders  to  rest  upon. 
This  contraction  is  much  more  frequent  than  the  former;  and  is 
for  the  most  part,  the  greatest  obstacle  we  have  to  encounter, 
when  we  attempt  to  turn,  after  the  waters  have  long  been  drained 
off.  It  will  readily  be  perceived,  that  it  is  essential  to  either  of 
these  cases,  that  the  waters  be  discharged  ;  and,  as  far  as  my  own 
experience  will  justify  the  remark,  neither  of  these  contractions 
takes  place,  but  after  the  lapse  of  a  considerable  time;  at  least, 
to  the  degree  that  would  seriously  obstruct  delivery. 

672.  These  cases  necessarily  result  from  the  constant  disposi- 
tion which  the  uterus  has  to  return  to  its  original  size  and  shape, 
after  the  distending  cause  is  removed;  and  this,  as  I  have  else- 
where observed,  is  owing  to  its  constant  tendency  to  accommo- 
date itself  to  the  shape  and  inequalities  of  its  contents,  by  virtue 
of  its  tonic  power — hence  the  contractions  in  question. 

673.  When  either  of  these  conditions  complicates  the  labour, 
it  will  soon  become  for  many  hours  stationary,  or  nearly  so;  and 
whatever  other  cause  may  combine  with  the  existing  one,  to 
render  immediate  delivery  either  desirable,  or  indispensable,  it 
will  be  found  almost  impracticable  to  perform  it  by  any  means. 
If  we  attempt  to  turn,  we  shall  find  it  almost  impossible  to  in- 
sinuate the  hand  into  the  orifice  of  the  uterus,  so  as  to  dilate  it 
sufficiently,  to  permit  it  to  pass  to  the  feet ;  and  if  we  apply  the 
forceps,  we  can  only  deliver  at  the  risk  of  tearing  the  uterus ; 
especially,  in  the  first  of  these  cases.     In  the  second,  Baude- 


244  PARTIAL  CONTRACTIONS  OF  THE  UTERUS. 

locque  says,*  "though  it  may  in  some  cases  produce  as  great  an 
ohstacle  to  delivery,  it  is  always  easier  to  overcome  it,  and  the 
same  inconveniences  do  not  result  from  it;  because  the  head  is 
not  so  far  engaged,  and  may  always  be  pushed  back ;  which  per- 
mits us  to  advance  the  hand  under  the  uterine  circle  in  question, 
and  dilate  it."  I  do  not  altogether  agree  with  this  high  authority 
on  this  point;  for  I  have  certainly  met  with  this  case,  where  I 
could  not  push  back  the  head,  and  thus  dilate  the  stricture ;  and 
also,  I  have  found  there  was  no  possible  advantage  in  merely 
overcoming  this  resistance  by  passing  the  hand  by  force  through 
the  contraction,  so  long  as  the  stricture  continued  in  force,  after 
the  hand  was  thus  passed.  For  if  the  contraction  be  not  entirely 
removed,  or  so  weakened,  as  to  yield  to  a  moderate  force,  there 
is  nothing  gained  by  bringing  down  the  feet  to  the  orifice  of  the 
uterus, or  even  lower;  for  the  instant  the  breach  descends  to  this 
stricture,  its  progress  is  arrested  by  the  inclined  plane  I  have 
just  spoken  of:  and  no  force  that  could  safely  be  exerted,  will 
make  it  pass  through  this  narrowed  portion  of  the  uterus. 

674.  Of  the  first  of  these  cases,  I  can  find  but  one  upon  my 
records ;  nor  have  I  any  recollection  that  I  have  ever  encounter- 
ed more.  Baudelocque  says  he  has  seen  but  one ;  it  must  there- 
fore be  of  rare  occurrence.  Of  the  second  I  have  witnessed  many; 
indeed  I  believe  it  will  be  almost  always  found  where  the  waters 
have  been  long  evacuated,  and  when  the  pains  are  feeble  and 
transitory  for  many  hours  after.  I  have  rarely  failed  to  find  it, 
when  it  has  been  expedient  to  finish  a  labour  by  turning;  where 
tediousness  and  other  causes  have  rendered  this  interference  ne- 
cessary. And  it  is  one  of  the  most  usual,  as  well  as  one  of  the 
most  obstinate  and  insurmountable  causes,  which  oppose  turning 
in  the  contracted  uterus. 

675.  These  cases  may  be  suspected  whenever  there  is  no  ad- 
vancement of  the  labour,  though  the  pains  be  very  severe;  and 
there  is  neither  a  contracted  pelvis,  nor  a  bad  situation  of  the 
head,  nor  a  rigidly  closed  os  uteri  to  account  for  the  delay — 
where,  during  the  pain,  the  head  is  found  to  descend,  and  gives 
temporary  assurance  that  delivery  will  take  place  pretty  soon: 
hut  where  these  hopes  are  instantly  destroyed  by  the  head  being 
quickly  retracted,  so  soon  as  the  pain  shall  cease  to  urge  it  down- 
wards.t     And  they  may  be  ascertained  by  passing  the  hand  be- 

»  System,  par.  1118. 

-j-  This  case  must  not  be  confounded  with  that  retraction  of  the  head  which 


PARTIAL  CONTRACTIONS  OP  THE  UTERUS.        245 

yond  the  head  of  the  child— in  the  first  case  the  lower  circle  of 
the  OS  uteri  will  be  found  round  the  child's  neck ;  in  the  second, 
the  higher  circle  will  be  found  in  the  same  situation. 

676.  Lest  this  should  not  be  accurately  comprehended,  we 
shall  again  advert  to  the  neck  of  the  uterus,  when  this  organ  is 
either  not  impregnated,  or  not  beyond  the  sixth  month — in  either 
case,  the  neck  of  the  uterus  will  be  found  to  have  two  openings, 
or  lather  two  circles;  the  one  inferior,  or  that  which  constitutes 
the  OS  tincre;  the  other  superior,  and  constitutes  the  upper  part 
of  the  neck,  or  the  inferior  portion  of  the  body  of  this  organ 
(107.)  At  the  latter  end  of  gestation,  the  neck  is  entirely 
effaced;  (200)  but  no  sooner  is  the  distending  cause  removed, 
than  the  fundus,  body,  and  neck,  set  about  moulding  themselves 
into  their  original  form;  and  consequently,  in  such  a  manner,  as 
will  indicate  the  portion  which  will  ultimately  become  neck. 
This  being  the  case,  the  whole  of  the  portion  which  forms  this 
part,  will  contract,  so  soon  as  the  distending  cause  is  removed; 
now  if  the  head  has  entirely  passed  through  the  lower  circle,  this 
part  will  contract,  because  distention  is  removed;  and  as  the  neck 
is  much  smaller  than  the  head,  it  will  close  round  it,  and  form 
the  first  case  in  question;  but  if  the  head  is  but  in  part  through 
the  lower  circle,  the  upper  circle  will  contract  at  the  part  oppo- 
site the  neck,  and  form  the  second  case. 

677.  The  management  of  these  cases  is  by  no  means  so  well 
understood,  as  to  free  them  from  all  embarrassment,  even  to  prac- 
titioners of  considerable  standing;  this  has  arisen  perhaps  from 
their  not  having  been  well  described  by  any  author  with  which 
we  are  acquainted,  except  Baudelocque;*  and  his  account  is  de- 
fective as  regards  the  treatment,  as  it  does  not  inform  us  how  we 
are  to  overcome  the  constriction,  after  the  hand  has  passed  it;  for 
if  we  do  not  find  means  to  relax  it,  or  very  much  abate  its  force, 
the  breech  cannot  be  made  to  pass.  I  will  point  out  the  mode  I 
have  pursued  in  such  instances,  by  relating  a  case  extracted  from 
my  "Essay  on  the  Means  of  lessening  Pain,  &c."  p.  137. 

G78.   "1798,  December  18th:  I  was  called  to  Mrs.  Z ,in 

labour  with  her  third  child;  she  had  been  in  pain  for  forty-eight 

take  place,  when  the  parietal  protuberances  ai'e  about  to  pass  below  the  tubers 
of  the  ossa  ischia ;  and  supposed  by  some  to  indicate  too  short  a  funis — this 
last  takes  place  only  at  the  last  period  of  laboiu";  whereas  the  other  occurs  be- 
fore tlie  head  occupies  the  lower  strait. 
*  System,  Vol.  II.  p.  111.  par.  1117,  1118. 


246  PARTIAL  CONTRACTIONS  OP  THE  UTERUS. 

hours;  waters  discharged  thirty-six;  the  uterus  well  dilated; 
pains  severe,  but  no  advancement  of  the  child;  during  the  pain, 
the  child's  head,  which  was  well  situated,  would  be  forced  down, 
but  as  soon  as  it  ceased  it  would  again  be  retracted;  this  had  been 
the  case  many  hours  before  I  saw  her.  In  order  to  ascertain  the 
cause  of  this  delay,  I  introduced  my  hand  into  the  uterus,  and 
presently  found  the  cause  of  the  child  not  advancing;  a  circle  of 
the  uterus  had  closed  between  the  shoulders  of  the  child  and  its 
head,  which  prevented  the  former  from  passing.  I  bled  her  to 
fainting;  pains  soon  came  on,  and  she  was  quickly  delivered." 

G79.  This  case  terminated  without  the  necessity  of  turning,  but 
I  have  not  been  always  so  fortunate;  some  cases  which  I  have  wit- 
nessed have  required  this  operation,  and  others  the  forceps.  The 
value  of  this  case  consists  chiefly  in  showing  the  very  decided 
efficacy  of  blood-letting,  and  has  been  quoted  for  this  purpose 
principally,  as  it  is  the  remedy  which  should  always  be  employed 
in  such  cases,  and  should  be  carried  to  the  extent  mentioned.  It 
is  the  only  remedy  with  which  I  am  acquainted,  that  has  a  de- 
cided control  over  the  contracted  uterus;  it  is  one  almost  certain 
of  rendering  turning  practicable  under  such  circumstances,  if 
carried  to  the  extent  directed — a  small  bleeding  in  such  cases  is 
of  no  kind  of  advantage;  for,  unless  the  practitioner  determine 
to  carry  the  bleeding  to  its  proper  length,  which  is  a  disposition 
to,  or  the  actual  state  of  syncope,  he  had  better  not  employ  it. 

680.  Turning  must  not  be  thought  of  in  the  first  of  these  spe- 
cies, as  the  head  is  without,  or  escaped  through,  the  os  uteri;  the 
forceps  are  the  only  proper  remedy  in  this  case:  but  before  they 
are  employed,  the  same  precaution  of  an  extensive  bleeding 
should  be  premised,  or  otherwise  the  most  serious  mischief  may 
follow — either  the  uterus  would  suffer  a  laceration  at  the  stric- 
ture, or  it  would  be  dragged  with  the  child's  shoulders  through 
the  external  parts. 

681.  The  cases  in  which  I  have  the  oftenest  experienced  the 
good  effects  of  blood-letting,  were  of  the  second  kind  of  my  divi- 
sion; but  as  I  am  certain,  from  what  I  have  seen,  it  would  be 
equally  proper,  and  equally  successful  in  the  first — in  reasoning 
upon  the  subject,  I  should,  a  priori,  think  it  would  be,  if  possible, 
more  so  in  the  first  than  in  the  second  species;  as  there  are  fewer 
fibres  concerned  in  that  portion  of  the  uterus  which  forms  the 
stricture;  and  besides,  we  have  the  most  ample  experience  of  its 


COMPOUND  PREGNANCY.  247 

good  effects,  in  the  rigid  state  of  the  os  uteri,  before  it  has  be- 
come dilated. 

682.  When  bleeding  is  determined  on,  the  blood  should  be 
drawn  from  a  large  orifice,  and  the  woman  placed  upon  her  feet, 
if  practicable — much  less  blood  will  answer,  if  the  bleeding  be 
conducted  in  this  way. 

Sect.  VII. — 7.  Comjwund  Pregnancy. 

683.  When  pregnancy  consists  of  twins,  or  of  more  children, 
it  will  be  found  that  the  uterus  does  not,  nor  indeed  cannot,  act 
as  favourably  for  their  expulsion,  as  if  there  was  but  one  child. 
The  reason  of  this  is  obvious  even  with  twins;  since,  in  such  cases, 
the  uterus  cannot  close  upon  the  whole  surface  of  a  child  at  once; 
its  force  is  consequently  exerted  in  such  a  manner  as  that  both 
children  must  receive  a  part  of  the  influence;  and  both  of  course, 
will  be  pressed  equally,  or  nearly  so,  towards  the  opening  of  the 
pelvis,  but  in  which  both  cannot  engage  at  one  and  the  same 
time.  This,  in  some  cases,  will  create  a  difficulty  from  the  very 
commencement  of  labour;  which  cannot  always  be  overcome,  by 
the  natural  agents  of  delivery ;  the  labour  will  therefore  be  pro- 
tracted, as  well  as  painful;  and  sometimes  no  alternative  is  left 
but  artificial  means,  to  finish  the  labour;  hence,  the  frequent  ne- 
cessity to  interfere — this  case  will  sometimes  require  turning,  at 
other  times  merely  bringing  down  the  legs,  &c. 

684.  Embarrassment  may  sometimes  be  created  even  in  the 
best  positions  that  twins  can  take ;  and  this  will,  consequently, 
be  increased,  when  they  offer  untowardly  at  the  opening  of  the 
pelvis  ;  when  one  or  both  may  be  hydrocephalic,  or  have  the 
abdomen  loaded  with  water ;  when  there  shall  be  more  than  two 
children ;  when  two  may  be  joined  together,  creating  a  monster, 
&c.  No  distinct  rules  can  be  laid  down  for  the  management  of 
such  cases:  interference  almost  always  becomes  indispensable — 
but  the  precise  mode  of  acting,  must  be  left  very  much  to  the 
good  sense,  and  discretion  of  the  accoucheur. 

685.  Independently  of  the  obstacles  arising  from  the  compound 
nature  of  the  pregnancy,  or  the  awkward  situation  of  the  chil- 
dren which  compose  it,  this  labour,  like  every  other,  may  be  com- 
plicated by  any  of  the  accidents  already  enumerated,  and  thus 
require  immediate  delivery.  But  should  interference  be  consi- 
dered indispensable  to  the  relief  of  the  woman,  it  must  not  be 


248  PROLAPSUS  OF  THE  UMBILICAL  CORD,  &Cc 

carried  into  execution  before  the  uterus  is  in  a  proper  condition, 
as  has  been  constantly  insisted  on,  in  every  other  case  in  which 
it  is  necessary  to  pass  the  hand  into  it,  for  the  purpose  of  deli- 
very.    See  Chapter  on  Twins,  &c. 

686.  Should  the  nature  of  the  case  be  such  as  to  render  turn- 
ing either  improper  or  impracticable;  that  is,  if  the  head  of  the 
child  cannot  be  easily  moved  up,  in  consequence  of  its  being 
wedged  by  another  child;  or  so  low,  that  it  would  be  dangerous, 
after  the  long  escape  of  the  waters  to  attempt  turning;  or  after  it 
has  escaped  from  the  neck  of  the  uterus,  we  must  then  terminate 
the  labour  by  the  forceps. 

Sect.  VIll.— S.  Prolapsus  of  the  Umbilical  Cord^  S^c. 

687.  It  is  a  matter  of  some  surprise  that  the  case  now  under 
consideration,  should  not  occur  more  frequently  than  it  does; 
since,  we  do  not  perceive  that  any  part  of  the  economy  of  labour, 
or  the  natural  order,  or  disposition  of  the  foetus  and  its  cord  with- 
in the  utcrus;  appear  calculated  to  prevent  it;  yet,  comparatively, 
a  prolapsus  of  the  cord  is  an  event  of  rare  occurrence.  With  re- 
spect to  its  becoming  a  case  of  preternatural  labour,  it  is  only  to 
be  considered  such,  while  there  is  circulation  in  the  cord ;  and 
when  there  is  evidently  a  risk  of  its  being  interrupted,  before  de- 
livery can  take  place  by  the  natural  agents,  in  time  to  save  the 
child.  When  this  occurs,  turning  may  be  had  recourse  to— 1st. 
When  the  uterus  is  sufiiciently  dilated  or  easily  dilatable ;  2d. 
When  the  head  is  enclosed  in  the  uterus,  and  the  waters  have  not 
been  too  long  discharged;  3d.  When  there  is  no  deformity  of 
pelvis  to  defeat  the  object.  Should  the  forceps,  however,  be  at 
hand  when  the  head  is  low,  and  the  cord  in  danger  of  compres- 
sion, or  actually  compressed ;  we  should  without  hesitation  em- 
ploy them.     See  Chapter  on  Prolapsus  of  the  Cord. 

Sect.  IX. --9.    Too  Short  a  Cord. 

688.  It  is  said  that  too  short  a  cord,  either  natural  or  artificial, 
will  interrupt  a  natural  labour  and  oblige  us  to  finish  it  by  turn- 
ing. 1  shall  not  positively  deny  the  existence  of  such  a  condition 
of  the  cord;  but  I  must  say,  I  have  never  seen  an  instance;  and 
also,  that  I  entertain  strong  doubts  of  its  possibility.  See  Ciiap- 
ter  on  Prolapsus  of  the  Cord. 


BAD  POSITION  OF  THE  HEAD,  &C.  249 

Sect.  X. — 10.  Of  the  Bad  Position  of  the  head,  though  the 
Vertex  may  presetit. 

689.  It  is  not  simply  because  the  vertex  presents,  that  this  la- 
bour is  in  general  esteemed  the  best — it  can  only  be  considered 
strictly  so,  when  the  great  diameter  of  the  child's  head,  shall  cor- 
respond with  that  of  the  pelvis,  and  while  this  part  maintains  a 
certain  position  in  its  course,  as  well  as  describes  a  given  route, 
in  that  course — therefore,  the  third  and  sixth  presentations  must 
be  essentially  bad;  since  with  them  the  reverse  of  a  good  presen- 
tation obtains ;  that  is,  the  great  diameter  of  the  head  offers  to 
the  small  diameter  of  the  superior  strait,  in  both  cases;  besides 
the  sixth  having  the  disadvantage  of  the  forehead  coming  under 
the  arch  of  the  pubes. 

690.  But  if  the  head  present  in  the  best  possible  manner  at  the 
superior  strait,  it  gives  no  absolute  securit}^,  it  shall  continue  so; 
since,  it  may  depart  from  the  route,  which  is  essential  to  an  easy 
labour.  Therefore,  the  labours  in  which  the  vertex  present,  may 
require  interference  from  four  different  causes:  a.  from  the  ver- 
tex presenting  to  the  small  diameter  of  the  superior  strait,  as  hap- 
pens in  the  third  and  sixth  presentations,  b.  From  the  chin  de- 
parting from  the  breast  too  early ;  though  at  first  a  proper  relation 
existed  between  the  head  and  pelvis,  c.  From  the  presence  of 
the  face ;  owing  to  the  excessive  departure  of  the  chin  from  the 
breast,  or  the  retiring  of  the  vertex,  toward  the  back.  d.  From 
some  part,  as  the  hand,  or  arm,  accompanying  the  head ;  though 
the  latter  was  at  first  well  situated. 

a.  Bad  Position  of  the  Vertex. 

691.  In  the  third  presentation  of  the  head,  the  vertex  offers  to 
the  pubes,  and  the  anterior  fontanelle  to  the  sacrum.  Should  the 
pelvis  be  ample,  or  the  head  not  too  large,  which  virtually  amounts 
to  the  same  thing,  the  natural  powers  concerned  in  labour  will  be 
every  way  competent  to  its  accomplishment ;  but  should  the  re- 
verse obtain,  great  difficulty  may  be  experienced ;  or  the  labour 
may  be  even  impracticable,  without  extraneous  assistance.  When 
the  difficulty  to  deliver  depends  exclusively  upon  position,  we 
have  nothing  to  do,  but  to  change  it,  to  remedy  the  evil ;  and  then 
commit  it  to  nature,  provided,  she  appear  immediately  competent 
to  this  end — that  is,  if  the  pains  are  effective,  and  the  labour 
32 


250  CHIN  DEPARTING  TOO  EARLY  FROM  THE  BREAST. 

advances  with  sufficient  rapidity,  to  justify  its  being  trusted  to 
the  natural  powers.  (See  694.) 

692.  When  we  are  about  to  rectify  the  position  of  the  vertex, 
the  woman  must  be  placed,  as  will  be  directed  by  and  by;  the 
hand  introduced  into  the  vagina;  the  head  grasped  by  insinuating 
the  thumb  and  fingers  within  the  orifice  of  the  uterus,  in  such  a 
manner  as  the  fingers  shall  lie  on  one  side  of  the  head,  and  the 
thumb  on  the  other;  the  head  must  then  be  raised,  so  as  to  dis- 
engage it  from  the  superior  strait,  and  the  vertex  turned  towards 
one  of  the  acetabula — if  the  right  hand  be  used,  turn  it  towards 
the  right  acetabulum;  if  the  left,  to  the  left  acetabulum;  and 
then  trust  the  rest  to  nature. 

693.  But  should  any  of  the  accidents  already  enumerated  com- 
plicate the  labour,  and  render  delivery  immediately  necessary, 
we  must  turn,  and  deliver  by  the  feet;  provided  the  os  uteri  be 
in  a  proper  condition. 

694.  If  it  be  the  sixth  presentation,  we  must  proceed  as  direct- 
ed above,  (692,)  and  reduce  the  situation  of  the  head,  to  either 
the  fourth,  or  the  fifth;  and  then  commit  it  to  the  natural  powers 
for  furtherance.  It  must  be  remembered,  that,  when  the  sixth 
presentation  is  changed  to  the  fourth  or  fifth,  we  must  not  at- 
tempt its  further  reduction,  as  recommended  for  these  presenta- 
tions, when  they  originally  offer  in  these  positions;  as  this  at- 
tempt, if  even  successful,  as  regards  the  alteration  of  position, 
will  necessarily  destroy  the  child,  by  the  excessive  twist  the 
neck  must  undergo  in  the  operation.  Should  any  of  the  accidents 
mentioned  above  complicate  the  labour,  we  must  turn,  and  deli- 
ver by  the  feet;  as  directed  for  the  third  presentation.  (691.)  Or, 
if  the  waters  have  long  been  expended,  or  the  uterus  in  a  state  of 
inertia,  we  must  give  the  ergot,  or  apply  the  forceps.  See 
Chapter  on  Forceps. 

b.  Chin  departing  too  early  from  the  Breast. 

695.  When  treating  of  the  mechanism  of  labours  of  the  vertex, 
I  remarked  that  the  chin  rested  upon  the  breast  of  the  child  (627) 
until  the  vertex  or  forehead  were  about  to  emerge  from  under  the 
arch  of  the  pubes;  and  that  this  position  of  the  chin  was  essen- 
tial to  a  natural,  or  easy  labour;  when  the  chin  does  not  confine 
itself  to  the  breast  until  the  proper  time  for  leaving  it,  the  longi- 
tudinal diameter  (87)  of  the  child's  head  will  ofier  to  the  small 
diameter  of  the  lower  strait,  at  the  last  period  of  labour;  and  thus 
present  almost  insuperable  difficulties  to  delivery. 


CHIN  DEPARTING  TOO  EARLY  PROM  THE  BREAST.  251 

696.  This  case  is  known  at  the  beginning  of  labour,  by  the 
anterior  fontanelle  being  found  in  the  centre  of  the  pelvis;  and, 
at  the  last  2)eriod,  by  this  part  being  at  the  bottom,  or  rather  the 
lowest  part  of  the  child's  head,  and  resting  on  the  internal  face  of 
the  perinseum ;  by  one  of  the  parietal  protuberances  offering  un- 
der the  arch  of  the  pubes;  and  by  the  forehead  being  placed  on 
one  side  of  the  pelvis;  but  the  side  to  which  it  will  offer,  will 
depend  upon  whether  it  was  a  first  or  fifth,  or  a  second  or  fourth 
presentation,  that  was  disturbed.  If  either  of  the  two  first,  the 
forehead  will  be  to  the  right  side ;  if  either  of  the  two  latter,  it 
will  be  to  the  left. 

697.  Various  causes  have  been  assigned  for  the  production  of 
this  very  untoward  situation  of  the  head ;  Levret  supposed,  it 
was  owing  to  the  shoulders  being  arrested  at  the  superior  strait, 
in  consequence  of  the  oblique  situation  of  the  child's  body;  while 
Baudelocque  contends  it  arises  from  the  direction  of  the  expulsive 
forces  of  the  uterus,  and  the  manner  in  which  they  act  upon  the 
child's  head;  and  this  opinion  appears  to  be  well-founded. 

698.  The  indication  in  this  situation  of  the  head  is,  to  restore 
the  chin  to  the  breast;  this  may  be  effected  at  two  different  pe- 
riods of  the  labour;  first,  where  the  head  has  not  descended  en- 
tirely into  the  lower  strait;  and  second,  where  it  occupies  the 
lower  strait.  As  regards  both  convenience,  and  certainty,  the 
first  situation  of  the  head  is  the  preferable  to  operate  upon ;  and, 
where  practicable,  should  be  chosen.  But,  to  act  with  success, 
it  is  necessary  that  the  os  uteri  should  be  well  dilated,  the  mem- 
branes ruptured,  and  the  pains  sufficiently  brisk.  The  mode  of 
acting  in  this  case  is  very  simple;  first,  rectify  the  obliquity  of 
the  uterus,  by  placing  the  woman  upon  the  side  opposite  to  the 
deviation,  if  it  be  either  the  right  or  left  lateral  obliquity  that 
prevails;  or  upon  the  back,  if  the  anterior;  second,  in  the  ab- 
sence of  pain  push  up  the  forehead,  and  maintain  it  in  that  posi- 
tion by  making  a  fulcrum  of  the  points  of  two  or  three  fingers; 
when  a  pain  comes  on,  maintain  the  resistance,  by  supporting  the 
forehead  with  the  fingers,  until  the  vertex  is  found  to  descend, 
and  the  forehead  to  I'ise  in  the  pelvis ;  when  this  is  done,  the  de- 
livery of  the  head  may  be  trusted  to  nature.  I  believe  it  will 
not  always  be  necessary  to  introduce  the  whole  hand,  in  the  first 
condition  of  the  head,  though  perhaps  absolutely  necessary,  in  the 
second. 

699.  Baudelocque  recommends  acting  upon  the  forehead  in 


252  CHIN  DEPARTING  TOO  EARLY  FROM  THE  BREAST. 

the  time  of  pain;  I  am  aware,  that  it  is  rarely  safe  to  differ  from 
this  high  authority ;  yet  I  am  equally  convinced,  it  is  occasionally 
proper  to  do  so — and  the  case  we  are  considering,  is  one  in  point — 
first ;  because,  did  we  act  in  time  of  pain,  we  should  be  under  the 
necessity  of  overcoming  its  force,  before  we  could  raise  the  fore- 
head ;  this,  of  course,  would  be  a  work  of  supererogation;  second, 
by  acting  in  the  absence  of  pain,  we  can,  by  a  very  small  force, 
carry  the  forehead  as  high  as  we  wish,  and  can  maintain  it  in  the 
position  we  desire  it  to  take,  by  an  exertion  scarcely  greater,  than 
would  be  sufficient  to  raise  a  weight  equal  to  that  of  the  child's 
head;  third,  the  vertex  will  descend  as  a  matter  of  course,  if  the 
forehead  be  prevented  from  doing  so;  fourth,  by  acting  during 
pain  we  are  obliged  to  carry  the  forehead  in  direct  opposition  to 
the  action  of  the  uterine  forces,  which,  when  the  uterus  firmly 
embraces  the  head,  are  so  entirely  in  the  direction  in  which  the 
forehead  would  descend,  that  we  should  only  raise  the  fore- 
head, without  giving  an  opportunity  for  the  vertex  to  fall  into 
the  pelvis. 

700.  In  the  second  situation  of  the  head,  we  are  to  be  governed 
by  the  same  principles,  but  they  are  more  difficult  to  be  put  in 
execution;  in  this  case,  it  is  essential  to  success,  that  we  raise  the 
forehead  in  the  absence  of  pain ;  and  particularly,  if  the  head 
have  escaped  the  orifice  of  the  uterus;  when  this  is  the  case,  it 
requires  the  introduction  of  the  hand  to  raise  the  whole  head; 
this  should  always  be  done  first,  that  we  may  be  certain  of  keep- 
ing the  forehead  sufficiently  high  to  permit  the  vertex  to  descend. 
After  we  have  raised  the  head  sufficiently  towards  the  superior 
strait,  we  must  place  the  extremities  of  the  fingers  against  the 
posterior  edge  of  the  frontal  bone,  and  make  them  serve  as  fulcra, 
as  in  the  first  instance.  (69S)  In  doing  this,  we  should  carefully 
avoid  pressure  upon  the  anterior  fontanelle  itself.  When  the  po- 
sition is  rectified,  we  must  withdraw  the  hand,  and  let  nature 
perform  the  rest. 

701.  I  have  dwelt  upon  this  case,  because  it  is  one  of  great 
consequence  to  both  mother  and  child — for  if  it  be  improperly 
managed,  the  child  will  too  often  fall  a  sacrifice  to  the  method  em- 
ployed, and  the  mother  will  incur  the  risk  which  always  attends 
embryulcia.  For  it  is  a  case  in  which  the  forceps  would  fail  to 
relieve,  since  the  head  cannot  be  made  to  leave  the  pelvis  in  the 
direction  it  has  descended  to  the  lower  strait;  for  the  longitudi- 
nal diameter  will  be  found  parallel  to  the  small  diameter  of  this 


CHIN  DEPARTING  TOO  EARLY  PROM  THE  BREAST.  253 

strait.  Turning  will  be  rarely  possible,  were  it  resolved  upon; 
since  in  the  second  situation,  the  person  who  has  charge  of  the 
case,  and  who  must  be  supposed  ignorant  of  the  principles  which 
should  govern  it,*  will  permit  a  great  deal  of  time  to  pass,  after 
the  escape  of  the  waters,  under  the  hope  that  every  pain  will  de- 
liver the  head,  because  of  its  nearness  to  the  opening  of  the  pel- 
vis; he  will  at  this  time  most  probably  find  the  head  free  from 
the  mouth  of  the  uterus,  in  which  case,  turning  must  ever  be 
forbidden,  or  if  it  have  not,  the  uterus  will  be  so  firmly  contract- 
ed upon  the  body  of  the  child,  as  to  render  this  operation  im- 
practicable; embryulcia  is  then  the  only  resource  of  such  a  prac- 
titioner. 

702.  I  will  endeavour  to  illustrate  this  subject,  by  the  relation 

of  a  case.     Mrs. was  under  the  care  of  a  young  practitioner 

of  midwifery,  with  her  fifth  child.  Her  labours  were  ordinarily 
rapid,  and  her  health  and  constitution  excellent.  She  was  attack- 
ed early  in  the  morning,  in  the  usual  manner  of  her  labours;  and 
her  accoucheur  gave  her  a  promise  of  speedy  relief;  her  pains 
were  strong  and  frequent;  the  uterus  was  well  dilated;  and  the 
membranes  burst  soon  after  his  arrival.  Every  expectation  was 
entertained  that  the  patient  would  soon  be  delivered;  the  head 
of  the  child  had  descended  to  the  inferior  strait;  but  after  a  short 
period,  the  head  was  found  not  to  advance.  Still  supposing  that 
nothing  could  prevent  the  delivery  of  a  head  so  near  to  the  loorld, 
he  constantly  gave  encouragement  to  his  patient,  until  her  pati- 
ence, and  that  of  her  friends,  were  exhausted — they  now  proposed 
a  consultation.  To  this  he  did  not  absolutely  object,  but  begged 
they  would  wait  another  hour  before  they  should  resolve,  assuring 
them  at  the  same  time  that  it  was  impossible  that  the  labour 
would  last  beyond  that  time — the  hour  passed  away  without  this 
hope  being  realized,  and  the  consultation  was  again  urged,  to 
which  he  reluctantly  consented,  from  a  firm  persuasion  that  it  was 
unnecessary.  I  was  now  sent  for,  (six  o'clock,  P.  M.)  but  I  hap- 
pened to.be  some  miles  in  the  country,  and  did  not  return  until 
after  eleven  o'clock,  and  by  the  time  I  saw  the  patient,  seventeen 
hours  had  elapsed  since  the  commencement  of  the  labour,  which, 
until  now,  had  rarely  occupied  two. 

•  The  person  who  has  charge  of  this  case  is  supposed  to  be  ignorant  of  its 
mechanism,  because  he  proposes  another  remedy  for  its  relief  than  the  reduc- 
tion of  the  forehead;  or  reprehensibly  waits,  in  the  hope  that  the  powers  of 
the  uterus  will  effect  the  delivery. 


254  CHIN  DEPARTING  TO  EARLY  FROM  THE  BREAST. 

703.  The  gentleman  in  attendance  gave  the  very  candid  state- 
ment related  above;  with  the  additional  declaration,  that  he  was 
"  at  his  wit's  end."  He  declared  he  could  not  possibly  conceive 
the  reason  of  this  very  unusual  delay,  and  begged  I  would  exam- 
ine the  patient.  This  I  did;  and  found  the  case  to  be,  the  too 
early  departure  of  the  chin  from  the  breast,  as  represented  in 
the  second  situation  of  this  presentation.  I  gave  my  opinion  to 
the  doctor;  and  tried  to  explain  the  mode  of  remedying  this  mal- 
position. He  undertook  the  operation,  under  the  persuasion  he 
understood  it;  and  I  was  anxious  he  should,  as  he  was  a  particu- 
lar friend  of  the  family,  and  was  just  getting  into  obstetrical  busi- 
ness. He,  however,  pretty  quickly  abandoned  the  side  of  his  pa- 
tient; and  earnestly  requested  I  would  do  what  was  necessary. 
I  had  the  patient  properly  placed,  and  introduced  my  hand  under 
the  head  of  the  child,  and  raised  it  up  to  a  sufficient  height,  and 
then  sustained  the  forehead  until  a  pain  come  on;  the  two  first 
pains  did  not  bring  down  the  vertex  as  I  had  hoped;  owing,  to 
the  very  firm  contraction  of  the  uterus  upon  the  body  of  the  child; 
I  nov/  directed  the  head  more  towards  the  right  sacro-iliac  junc- 
tion, and  had  the  satisfaction,  upon  the  accession  of  the  third 
pain,  to  have  the  vertex  descend  properly — I  withdrew  my  hand; 
and  the  head  was  delivered  the  next  pain,  to  the  great  joy  of  the 
mother;  the  safety  of  the  child;  and  the  astonishment  of  the 
doctor. 

704.  This  case  was  an  important  lesson  to  this  gentleman;  he 
called  upon  me  next  day,  and  begged  me  to  represent  the  pre- 
sentation upon  the  machine;  this  I  did  most  cheerfully,  to  his 
great  delight  and  satisfaction;  he  now  thoroughly  comprehended 
its  mechanism.  It  may  however  happen,  that  after  the  reduction 
of  the  head,  and  before  it  has  passed  through  the  external  parts, 
some  sudden  accident  may  complicate  the  labour,  and  oblige  us 
to  terminate  the  delivery  immediately;  in  such  case,  the  forceps 
must  be  used.  It  is  also  possible,  that  one  of  the  enumerated  ac- 
cidents may  complicate  the  labour  before  the  head  is  reduced; 
should  this  be  so,  it  would  be  best  to  turn ;  provided  the  circum- 
stances we  deem  essential  to  its  success  be  present;  or  unless  we 
should  be  convinced  there  will  be  no  important  time  lost,  in  at- 
tempting the  reduction.  Should  the  reduction  be  undertaken, 
and  it  succeed,  the  labour  may  be  finished  by  the  forceps,  if  the 
natural  powers  are  not  promptly  suflicicnt. 


CASES  IN  WHICH  THK  FACE  PRESENTS.  255 

c. — Cases  in  ivhlch  the  Face  jjresenis.'^ 

705.  The  face  may  present  at  the  superior  strait  in  four  differ- 
ent manners — the  most  common  is,  where  the  forehead  offers  to 
the  left,  and  the  chin  to  the  right  side  of  the  pelvis  ;  2d,  is  the 
reverse  of  this;  3d,  the  forehead  answers  to  the  symphysis  of  the 
pubis,  and  the  chin  to  the  sacrum;  the  fourth,  is  the  reverse.  In 
face  presentations  the  woman  always  finds  a  difficulty  in  deliver- 
ing herself;  and  delivery  can  only  take  place  in  a  well-formed 
pelvis,  when  the  head  is  in  this  position.  They  may,  therefore, 
be  considered,  without  many  exceptions,  as  essentially  bad,  or 
preternatural  presentations.  Some  authors  have  considered  them 
so  exclusively  such,  as  to  recommend  turning  wherever  the  face 
ofiers.t  I  would  not  be  considered  as  constantly  recommending 
this  practice;  yet  I  am  persuaded,  that  should  the  third  or  fourth 
of  these  presentations  occur,  it  would  be  the  best  practice;  espe- 
cially, where  we  could  have  the  choice  of  the  time,  and  the  con- 
ditions. Turning  is  always  attended  with  more  or  less  risk  to 
the  child,  however  favourable  the  situation  of  the  uterus  may  be 
for  the  operation,  or  however  dexterously  it  may  be  performed; 
I  may  say  the  same,  however,  efface  presentation  ;  especially,  in 
the  two  last ;  and,  above  all,  ahould  the  pelvis  be  rather  con- 
tracted or  the  head  large  ;  therefore  in  such  cases,  there  is  only  a 
choice  of  evils. 

706.  It  will  be  perceived,  by  the  reader  who  may  be  familiar 
with  the  divisions  of  this  presentation  by  Baudelocque,  that  I  have 
reversed  his  order.  There  is  a  propriety  in  this;  as  I  hold  it  to 
be  a  good  rule,  to  place  first  in  the  numerical  arrangement,  the 
most  frequent  of  a  particular  presentation— and  I  am  persuaded, 
as  far  as  I  dare  trust  my  own  experience,  that  the  first  and  second 
of  my  arrangement,  are  by  far  the  most  common — nay,  I  may  go 
farther,  and  declare,  I  have  hitherto  not  met  with  either  the  third 
or  fourth ;  (the  first  and  second  of  Baudelocque,)  and  indeed  some 
doubt  may  be  entertained  whether  they  have  ever  occurred— 

»  It  would  seem  but  natural,  that  the  flice  presentations  should  be  hicluded 
in  the  order  of  the  vertex;  since  they  are  but  instances  of  the  vertex  disturbed. 

t  Dr.  Davis  is  the  latest  author  that  advocates  indiscriminate  tm-ning-,  in  face 
presentations.  He  directs,  "When  the  foce  is  discovered  to  present  at  the 
brim  of  the  pelvis  at  an  early  period  of  a  labour,  whctlier  before,  or  very  soon 
after  the  escape  of  the  liquor  amnii,  there  can,  in  my  opinion,  be  no  doubt  of 
the  preferableness  of  tui-ning,  to  aU  other  modes  of  U-catment."~ri;few,  Over 
Mid.  p.  245.)  .  ^ 


256  CASES  IN  WHICH  THE  FACE  PRESENTS. 

Bauclelocque  does  not  apjpear  to  speak  from  his  own  observation 
on  this  subject;  or  he  would  not  have  proposed  the  employment 
of  the  vectis,  for  the  reduction  of  the  vertex,  in  such  cases — a 
mode  of  acting,  I  believe,  that  can  never  succeed;  indeed  the 
vectis  cannot  be  made  to  reduce  the  vertex,  even  upon  the  ma- 
chine; as  I  have  frequently  demonstrated  to  my  pupils. 

707.  The  face  may  readily  be  distinguished  from  any  other 
part,  by  the  eyes,  the  nose,  the  mouth,  and  the  chin;  and  its  par- 
ticular situation  may  be  determined  by  this  last  feature,  and  the 
nose.  The  indication  in  these  labours,  if  it  is  determined  to  in- 
terfere with  them,  is  to  bring  down  the  vertex,  and  place  the 
chin  upon  the  breast.  Baudelocque*  says,  this  is  effected  by  ope- 
rating upon  the  vertex,  rather  than  pushing  up  the  chin — so  far 
as  my  experience  will  justify  differing  from  him,  I  should  declare 
that  pushing  up  the  whole  head  before  we  attempt  to  bring  down 
the  vertex,  though  the  head  may  still  be  at  the  superior  strait,  is 
essential  to  success.  And  farther,  that  we  should  always  press  the 
ball  of  the  thumb  against  the  highest  part  of  the  forehead,  and 
urge  it  upwards,  at  the  moment  that  we  are  endeavouring  to 
make  the  vertex  descend. 

708.  When  these  labours  are  terminated  by  the  natural  agents 
of  delivery,  they  are  always  very  tedious  and  painful;  the  child's 
face  comes  out  much  swoln  and  frequently  livid ;  the  eyes  tumid, 
and  the  child  itself  is  often  born  in  a  state  of  asphyxia. 

709.  The  proper  moment  for  acting,  either  as  regards  the  con- 
dition of  the  uterus,  or  the  situation  of  the  head,  can  rarely  be 
seized,  in  the  case  under  consideration;  for  before  the  membranes 
are  ruptured,  the  cases  cannot  be  easily  distinguished;  and  after 
they  are,  the  mouth  of  the  uterus  is  not  always  sufficiently 
relaxed  to  act  with  facility  or  advantage;  and  by  the  time  it  does 
dilate,  the  waters  may  have  been  so  long  drained  off,  as  to  ren- 
der the  attempt  fruitless. 

710.  In  the  first  and  second  presentations,  we  must  have  the 
concurrence  of  the  following  circumstances,  before  we  attempt 
the  reduction  of  the  head;  first,  the  uterus  must  be  sufficiently 
open  to  permit  the  hand  to  pass,  with  little  or  no  difficulty;  second, 
the  head  must  not  have  entirely  passed  the  superior  strait;  third, 
the  waters  must  have  been  recently  expended.  If  these  advan- 
tages combine,  after  having  the  woman  properly  placed,  a  hand 

*  System,  pur.  1337. 


CASES  IN  WHICH  THE  FACE  PRESENTS.  257 

must  be  passed  into  the  uterus:  and  the  choice  of  the  hand  is  a 
matter  of  the  first  consequence  to  the  success  of  the  operation: 
the  governing  rule  is  simple,  and  easily  remembered;  namely, 
the  hand  which  is  to  the  side  on  which  the  vertex  and  forehead  are 
placed;  that  is,  in  the  first,  the  right  hand  must  be  used;  because, 
when  before  the  patient,  the  right  hand  offers  to  the  left  side  of 
her,  or  the  pelvis;  if  the  second  be  the  presentation,  the  left  hand 
must  be  employed,  for  a  like  reason. 

711.  In  the  first  presentation  of  the  face,  we  pass  the  right  hand 
into  the  uterus  in  such  a  manner  as  shall  put  the  back  of  the 
fingers  to  the  posterior  part  of  the  pelvis,  or  before  the  left  sacro- 
iliac symphysis,  and  place  them  on  the  side  of  the  head,  while 
the  thumb  is  pressed  against  the  opposite  side;  the  head  is  then 
to  be  firmly  grasped,  and  raised  to  the  entrance  of  the  superior 
strait.  When  the  head  is  thus  poised,  the  extremities  of  the  fin- 
gers are  to  be  carried  over  the  vertex,  while  the  thumb  is  moved 
to  the  centre  of  the  upper  part  of  the  forehead;  the  fingers  are 
then  made  to  draw  the  vertex  downward,  while  the  thumb  tends 
by  its  pressure,  to  carry  the  face  upward,  thus  executing  a  com- 
pound action  upon  the  head.  All  this,  it  should  be  remembered, 
must  be  executed  in  the  absence  of  pain;  if  we  find,  when  pain 
comes  on,  that  the  vertex  moves  sufficiently  downwards,  and  the 
face  upwards,  to  give  assurance  it  will  now  descend,  we  may 
withdraw  the  hand,  and  trust  the  rest  to  the  action  of  the  uterus. 
But  if,  on  the  contrary,  upon  the  accession  of  the  pain,  we  find  the 
face  still  has  a  tendency  dovvnwards,  we  may  be  certain  that  the 
reduction  is  incomplete;  and  we  must  again  and  again  attempt  it, 
in  the  absence  of  pain,  if  it  be  necessary — for,  under  the  circum- 
stances I  have  stated,  we  are  pretty  sure  of  success  under  a  well- 
directed  management.* 

712.  In  the  second  presentation,  we  employ  the  left  hand,  un- 
der the  conditions  I  have  stated  for  the  first:  and  act  in  every 
respect  as  directed  for  that  presentation. 

713.  Should  however  the  above-stated  conditions  of  the  uterus 
not  be  present  at  the  proper  time;  or  should  the  head  have  de- 

•  Whenever  the  waters  have  been  evacuated  some  time,  the  operation  here 
ckscribed  will  be  embarrassed,  by  the  uterus  narrowing  itself  at  that  portion 
of  itself,  which  corresponds  to  the  neck  of  the  cliild;  and  will  thus  prevent  the 
reduction  of  the  head.  This  obstacle  must  not  be  attempted  to  be  overcome 
by  force — it  must  be  submitted  to  by  letting  the  head  advance  with  the  face 
foremost. 

33 


258  PRESENTATIONS  OF  THE  HEAD,  &C. 

scended  through,  (or  nearly  through,)  the  superior  strait,  we  can- 
not hope  to  succeed  by  any  attempt  made  with  the  hand  to  reduce 
the  vertex;  the  choice  of  remedy  will  then  lie  between  turning, 
and  the  vectis.  We  should  prefer  turning,  when  the  waters  have 
not  been  too  long  drained  off;  when  the  pains  are  not  either  very 
frequent  or  severe;  and  while  the  head  is  still  enveloped  in  the 
lower  part  of  the  uterus. 

714.  The  vectis  may  be  tried  under  the  contrary  condition  of 
things,  (710)  by  passing  it  up  the  side  of  the  pelvis,  until  it  pass 
over  the  vertex — when  it  is  placed,  we  must  endeavour  to  raise 
up  the  face  with  the  other  hand,  and  prevent  the  vertex  rising 
at  the  same  time,  by  a  counteracting  force  exerted  by  the  vectis; 
this  should  be  performed  in  the  absence  of  pain,  and  continued 
until  the  face  is  found  to  ascend,  and  the  vertex  descend.  If 
these  manoeuvres  succeed  in  getting  the  vertex  down,  we  may 
commit  the  rest  to  nature.  It  may,  however,  agreeably  to  my 
ovi^n  experience,  be  practicable  to  turn,  after  the  vectis  has  failed.* 

715.  In  the  third  and  fourth  species  of  face  presentations,  I  am 
persuaded,  it  would  be  losing  important  time  to  depend  upon 
any  other  mode  of  operating,  than  turning;  provided;  1st,  the 
uterus  be  sufBciently  dilated;  2d,  the  waters  but  recently  drain- 
ed off;  and  3d,  the  head  still  easily  movable,  at  the  superior  strait- 
Should  these  important  conditions  be  absent,  it  would  be  perhaps 
best,  (but  this  is  purely  spectilative,)  to  employ  the  hand  in  such 
manner,  as  will  guide  the  forehead  to  the  side  of  the  pelvis;  or 
in  other  words,  convert  it  into  a  first  or  second  presentation  of 
my  division  of  the  face,  and  then  attempt  the  reduction  of  the 
vei-tex  by  the  vectis,  or  deliver  by  the  forceps,  if  the  pains  are 
not  sufficiently  active;  or  the  ergot  should  be  tried. 

d.    Presentations  of  t lie  Heady  accompanied  witfi  tlie  Hand. 

716.  The  head  may  present  perfectly  well  as  regards  its  own 
position,  yet  may  be  accompanied  by  the  hand — the  presence  of 
the  hand  can  sometimes  be  detected,  before  the  membranes  have 
given  way;  and  when  it  is  found  in  this  situation,  it  is  almost 

*  Dr.  Davis  proposes,  for  the  reduction  of  the  vertex,  in  face  presentations,  a 
kind  of  vectis,  armed  witii  teeth.  Tiie  objection  to  such  an  instrument,  he  has 
urged  himself;  namely,  the  wound  inflicted  on  the  scalp  of  the  child,  &c.;  and 
we  every  way  sufficient  to  prohibit  its  use.  The  common  vectis,  as  I  have  ob- 
served, when  properly  managed,  in  proper  cases,  will  succeed,  as  I  have  ex- 
perienced. 


PRESENTATIONS  OP  THE  HEAD,  &C.  250 

sure  to  advance  with  the  head.  If  the  case  be  under  management 
at  this  moment,  the  presence  of  the  hand  can  rarely  create  any 
embarrassment  to  the  well-instructed  accoucheur;  he  knows, 
that  by  proper  management,  it  may  be  easily  prevented  from 
descending.  When  the  hand  accompanies  the  head,  it  should  be 
prevented  from  descending  with  it — this  for  the  most  part  is 
readily  managed,  by  placing  the  point  of  the  forefinger  between 
the  fingers  of  the  child,  and  preventing  its  farther  descent,  by 
supporting  it  during  a  pain;  and  at  the  same  time,  directing  the 
hand  towards  the  face.  When  this  is  properly  conducted,  the 
head  gets  under  the  hand,  and  makes  it  retire  within  the  cavity 
of  the  uterus. 

7i7.  When  this  case  is  neglected,  and  the  hand  permitted  to 
descend,  it  may  create  great  inconveniences,  especially,  in  a  nar- 
row pelvis:  1st,  by  obliging  the  head  to  turn  away  from  the  axis 
of  the  superior  strait,  and  making  the  shoulder  present  itself  in 
its  stead;  2d,  by  accompanying  the  head  in  its  descent,  and  pre- 
venting the  latter  from  making  the  proper  turns,  that  it  may  es- 
cape from  the  pelvis. 

718.  The  first  of  these  difiSculties  will  be  considered  under  the 
head  of  <"' shoulder  presentations,"  which  see;  and  the  other  will 
require  the  aid  of  the  forceps — it  occasionally  happens,  that  this 
situation  of  the  hand  and  arm  creates  considerable  embarrass- 
ment from  the  fixed  situation  it  gives  to  the  head,  as  well  as  the 
strong  and  perhaps  dangerous  compression  which  the  arm  suffers; 
also,  from  the  absolute  necessity  there  is  to  depart  from  one  of  the 
cardinal  rules  for  the  application  of  the  forceps,  (783)  by  placing 
them  upon  the  vertex  and  forehead;  as  the  following  case  will 
show.  I  was  called  upon  by  Dr.  Brown  to  visit  a  patient,  who 
had  been  long  in  labour  under  the  care  of  a  midwife,  in  conse- 
quence of  the  arm  being  included  between  the  symphysis  pubis, 
and  the  head;  the  labour  had  been  stationary  several  hours,  as 
the  head  could  not  descend,  though  she  had  had  frequent  and  se- 
vere pains,  but  which  were  becoming  more  and  more  feeble,  not- 
withstanding every  possible  exertion  of  the  poor  woman  herself 
—  the  arm  was  very  much  swollen,  the  scalp  pushed  down, 
while  the  head  was  completely  transverse,  as  regarded  the  pelvis 
— the  head,  in  consequence  of  the  long  absence  of  the  waters 
could  not  be  pushed  up,  therefore  turning  was  impracticable. 
After  having  the  woman  properly  placed,  I  applied  the'  forceps 
so  as  to  embrace  the  vertex  and  forehead — a  moderate  force  was 


260  EXHAUSTION. 

sufficient  to  bring  the  head  through  the  superior  strait ;  this  gave 
so  much  freedom  to  the  arm,  as  to  induce  me  to  withdraw  the 
instruments,  and  apply  them  comme  il  faut;  the  head  was  soon 
disengaged  ;  and  the  mother  and  child  did  well. 

719.  It  must  be  recollected,  that  the  head  is  not  the  only  part, 
which  the  hand  may  accompany;  it  may  present  with  the  breech, 
the  knees,  or  the  feet;  when  this  happens,  it  rarely  creates  any 
obstacle  to  delivery  per  se,  though  it  may  embarrass,  if  impro- 
perly acted  upon,  either  accidentally  or  designedly,  by  an  igno- 
rant practitioner.  Whenever  the  hand  is  perceived  at  the  supe- 
rior strait,  it  should  be  treated  as  above  directed,  (716,)  though 
the  attempt  to  retain  it  within  the  uterus  may  sometimes  be  un- 
availing, as  it  frequently  denotes  the  presence  of  the  shoulder  at 
the  upper  strait. 

Sect.  XL — 11.  Exhaitstion. 

720.  The  capacity  to  support  the  toil  of  labour,  will  vary  in 
almost  every  individual,  either  from  original  stamina,  or  the  se- 
verity of  the  process  itself.  Hence,  the  most  robust  woman,  as 
well  as  the  most  delicate,  may  become  exhausted  from  the  force 
or  the  long  continuance  of  labour — the  exhaustion  now  alluded 
to,  is  not  the  mere  loss  of  strength  in  the  muscular  system,  but  a 
sta4e  of  inertia  of  the  uterus  itself.  Both  these  conditions  may 
combine,  or  they  may  exist  separately,  and  independently;  when 
combined,  they  are  almost  always  accompanied  with  syncope; 
of  this,  I  have  already  treated;  when  they  exist  separately,  our 
conduct  must  be  regulated  by  the  system  which  suffers.  Should 
there  be  a  mere  loss  of  muscular  strength,  and  the  uterus  pre- 
serve its  powers,  it  will  offer  no  indication  as  regards  delivery; 
but  should  the  powers  of  the  uterus  be  upon  the  wane,  or  be  en- 
tirely suspended,  though  the  woman  possess  great  muscular  vi- 
gour, it  should  warn  us  not  to  confide  too  long  in  this  general  ap- 
pearance of  strength,  lest  the  uterus  itself  may  be  subjected  to 
casualties  independently  of  temporary  loss  of  vigour. 

721.  This  situation  of  the  uterus  may  arise  from  very  different 
causes,  and  require  very  different  modes  of  treatment;  first,  over- 
distention  from  an  excess  of  the  liquor  amnii;  when  this  is  the 
case,  we  find  the  pains  returning  at  rather  uncertain  intervals, 
and  confined  to  the  uterine  globe  ;  very  little  of  that  bearing  down 
sensation,  which  accompanies  the  healthy  protrusive  effort;  the 
membranous  bag  with  the  waters  is  not  very  tense  during  pain; 


EXHAUSTION.  261 

and  the  patient  experiences  a  general  restlessness  and  anxiety, 
when  pain  has  abated.  In  this  case  the  loss  of  power  is  only  re- 
lative, and  though  it  may  have  all  the  appearance  of  absolute 
weakness,  and  is  frequently  mistaken  for  it,  yet  it  is  not  truly  so; 
for  stimulants  but  increase  the  mischief,  by  exciting  the  arterial 
system,  and  goading  the  uterine  fibres  to  more  frequent,  but  to 
more  feeble  efforts.  The  remedy  in  this  case,  is  to  remove  the 
cause ;  namely,  the  liquor  amnii,  as  the  following  case  will  show. 

1796,  May,  16:  Mrs. ,  in  labour  with  her  first  child,  and 

of  good  constitution,  was  taken  with  feeble,  but  pretty  frequent 
pains  in  the  night,  which  she  bore  without  disturbing  her  family 
imtil  the  morning,  at  which  time  she  sent  for  her  midwife.  As 
the  pains  were  feeble,  and  transitory  at  the  time  of  the  arrival  of 
the  midwife,  she  told  her  her  labour  was  yet  too  weak  to  bring 
her  child,  and  she  would  call  again  in  the  course  of  an  hour — she 
did  so,  and  found  things  pretty  much  in  statu  quo;  she  again  took 
her  leave  and  did  not  return  until  towards  the  evening;  and  then 
it  was  in  consequence  of  a  summons  from  the  patient  who  had 
become  very  uneasy  and  restless:  enjoying  no  interval  of  comfort, 
though  the  pains  had  become  slower.  She  now  examined  the 
patient,  who  had  at  this  time  what  is  called  a  plentiful  show,  and 
the  OS  uteri  was  relaxed;  but  as  the  pains  made  very  little  im- 
pression upon  the  membranes,  she  concluded  this  could  only  arise 
from  iveakness;  she  accordingly  prescribed  strong  cinnamon  tea, 
and  a  stimulating  injection.  This  injection  afforded  a  temporary 
relief  by  discharging  a  large  quantity  of  hardened  faeces;  but  the 
pains  were  still  weak,  though  recurring  frequently.  The  patient 
became  feverish,  with  much  head-ache  and  thirst;  tlie  midwife, 
and  the  friends  of  the  patient  became  alarmed,  and  I  was  re- 
quested to  visit  her. 

722.  On  my  arrival,  I  received  the  above  account — I  waited  a 
few  minutes  to  observe  the  nature  of  the  pains,  as  well  as  to  as- 
certain other  particulars.  I  examined  the  uterine  globe  during 
pain,  by  placing  my  hand  upon  it,  and  found  it  to  harden  but  lit- 
tle; the  uterus  was  enormously  distended;  so  much  so,  as  to  have 
the  fundus  at  the  scrobiculus  cordis:  the  pulse  was  quick  and  full; 
there  was  also  considerable  head-ache.  I  examined  the  state  of 
the  uterus  per  vaginam,  and  found,  as  the  midwife  had  declared, 
a  relaxed  os  uteri;  or  at  least  a  yielding  one,  and  very  little  pres- 
sure upon  the  membranes  during  a  pain.  It  immediately  occurred 
to  me,  that  this  appearance  of  uterine  exhaustion  was  only  rela- 


2Q2  EXHAUSTION. 

live;  and  during  the  next  pain,  I  ruptured  the  membranes;  this 
gave  issue  to  a  prodigious  quantity  of  water;  frictions  were  insti- 
tuted upon  the  abdomen;  in  the  course  of  half  an  hour,  the  pains 
began  to  increase,  and  in  half  an  hour  more,  the  patient  was  safe- 
ly delivered,  after  a  labour  of  eighteen  hours,  which  might  have 
been  terminated  by  proper  management  in  six. 

723.  This  appearance  of  exhaustion  in  the  uterus  may  also 
arise  from  an  engorgement  of  this  organ;  it  will,  like  the  one  just 
mentioned,  stimulate  weakness,  or  want  of  power,  as  if  there  was 
positive  inertia  present — this  condition  may  be  known  by  the  la- 
bour having  come  on  kindly,  but  the  uterine  powers  are  found  to 
diminish  gradually;  the  os  uteri  disposed  to  dilate;  but  the  pre- 
senting part  is  not  protruded  during  pain;  and  the  pain  felt  over 
the  whole  abdomen.  The  woman  feels  a  sense  of  sufibcation,  or 
sinking;  the  pulse  is  hard,  full,  or  depressed;  and  the  pains  irre- 
gular, both  in  force  and  frequency.  This  case  is  only  to  be  re- 
lieved by  blood-letting;  the  following  case,  selected  from  a  num- 
ber of  the  kind,  will  illustrate  this  situation. 

1792,  August  17,  Mrs. ,  aged  twenty-eight  years,  in  labour 

with  her  first  child:  pains  commenced  regularly  and  pretty  se- 
verely, and  continued  to  be  so  for  some  time;  they  then  became 
desultory  in  frequency,  and  less  in  force — the  midwife,  before  I 
saw  her,  gave  her  some  stimulating  drinks,  which  increased  cer- 
tain unpleasant  feelings ;  as  a  sense  of  suffocation,  heat  and  pain 
over  the  whole  of  the  abdomen,  sickness  at  stomach,  &c.  without 
augmenting  the  force  or  frequency  of  the  pains.  When  I  saw  her, 
she  was  labouring  under  all  the  distressing  symptoms  just  men- 
tioned, together  with  a  distressed  pulse,  frequent  sighing,  great 
uneasiness,  and  very  apprehensive  that  her  situation  was  danger- 
ous ;  the  mouth  of  the  uterus  was  but  little  dilated,  though  quite 
unresisting,  when  an  attempt  was  made  to  stretch  it ;  its  edges 
were  thickened,  but  not  tense ;  during  pain,  very  little  impression 
was  made  upon  the  child,  and  the  mouth  of  the  uterus  rather  con- 
tracted than  opened.  As  much  oppression  about  the  pracordia 
attended,  together  with  great  heat  in  the  abdomen,  she  was  or- 
dered to  lose  blood.  About  twenty  ounces  were  taken  before  the 
oppression  and  heat  were  much  diminished;  but  as  these  were 
relieved,  but  not  removed,  and  as  the  pulse  acquired  vigour  by 
the  operation,  I  was  induced  to  continue  the  bleeding  until  these 
unpleasant  symptoms  should  subside  ;  this  happened  upon  the  loss 
of  about  ten  or  twelve  ounces  more  of  blood.     The  pains  now  in- 


EXHAUSTION.  263 

creased  so  much,  that  in  about  twenty  minutes  she  was  safely 
delivered. 

724.  There  is  another  variety  of  this  exhausted,  or  rather  pas- 
sive state  of  the  uterus,  which,  if  not  well  understood,  may  mis- 
lead— it  is  where  labour  commences  with  the  usual  precursors, 
such  as  the  subsiding  of  the  abdominal  tumour;  the  secretion  of 
mucus;  forcing,  or  bearing  down  pains;  and  everything  giving 
promise  of  a  speedy  delivery.  After  these  favourable  appearances 
have  continued  a  longer  or  shorter  time,  the  pains  cease  altoge- 
ther, or  nearly  so,  without  evident  cause;  and  the  whole  labour 
seems  to  be  at  an  entire  stand.  The  pulse,  in  this  case,  is  very 
little  disturbed;  but  a  train  of  nervous  symptoms  supervenes;  such 
as  palpitation  of  the  heart;  great  oppression  about  the  praicordia, 
with  a  sense  of  suffocation,  if  the  patient  attempt  to  lie  down;  and 
a  disposition  to  syncope,  if  she  rise  up.  The  os  uteri  is  well  di- 
lated; and  the  membranes  remain  entire. 

725.  This  case  excites  much  alarm;  and  is  not  unfrequently 
treated  by  stimulating  medicines,  or  liquors,  by  ignorant  practi- 
tioners, to  the  injury  of  the  patient.  This  condition  of  the  uterus 
is  peculiar,  and  requires  the  administration  of  such  remedies  as 
may  have  a  specific  action  upon  its  fibres;  such  as  the  secalecor- 
nutum :  and  is  one  of  the  happiest  cases,  to  illustrate  its  powers, 
as  the  following  case  proves, 

1824,  March  14th,  I  was  called  in  haste  to  Mrs.  ,  whom 

I  found  perfectly  free  from  pain,  on  my  arrival.  I  was  however 
informed  that  her  pains  had  been  frequent,  and  strong,  previously 
to  her  sending  for  me;  indeed  so  much  so,  that  they  feared  I 
should  not  arrive  in  time.  She  experienced  pain  previously  to  my 
coming,  particularly  while  lying  on  the  bed:  to  relieve  which  she 
arose,  and  from  that  moment  she  was  easy.  She  complained  of 
a  most  distressing  pain  at  the  lower  part  of  the  sternum,  with  a 
sense  of  suffocation,  and  palpitation  of  heart.  I  waited  half  an 
hour  for  the  return  of  uterine  contraction,  but  it  did  not  take 
place.  She  was  requested  to  lie  down,  in  hope  it  would  produce 
their  renewal,  as  they  had  been  severe  while  in  a  horizontal  pos- 
ture— she  complied;  upon  examination,  the  os  uteri  was  found 
well  dilated,  and  the  head  occupying  the  lower  strait;  and  the 
membranes  entire.  I  waited  another  half  hour,  but  pain  not  re- 
turning, a  scruple  of  the  ergot  was  given;  in  fifteen  minutes  the 
pains  were  briskly  renewed,  and  she  was  soon  after  safely  deli- 
vered of  a  healthy  child. 


2G4    HiEMORRJIAGE  FROM  OTHER  PARTS  THAN  THE  UTERUS. 

726.  Exhaustion,  however.,  may  be  positive;  and  may  be  oc- 
casioned by  severe,  and  long-continued  exertion.  In  this  case,  the 
uterus  ceases  to  contract,  or  contracts  so  feebly  as  not  to  advance 
the  labour.  When  this  is  so,  the  general  strength  of  the  patient 
fails  also — she  becomes  listless,  and  indisposed  to  exertion;  she 
almost  always  sleeps  between  the  slight  pains,  if  they  exist,  or  if 
they  do  not,  she  continues  in  an  uneasy  and  disturbed  slumber, 
until  she  may  be  aroused  by  the  anxiety  of  her  friends,  or  by  offi- 
ciousness  in  oflering  her  something  to  "  refresh  her."  The  skin  is 
almost  always  damp,  or  even  sweating;  the  pulse  frequent  and 
small;  the  countenance  pale  and  haggard  ;  and  the  stomach  often- 
times much  disturbed. 

727.  The  original  cause  of  inertia  of  the  uterus,  is  very  fre- 
quently owing  to  the  rigidity  of  the  os  uteri,  or  external  parts  re- 
tarding the  labour,  until  the  uterine  powers  are  expended,  in  the 
attempt  to  overcome  it — when  this  happens,  the  relaxation  so 
much  desired  takes  place,  from  both  general  and  particular  weak- 
ness; but  the  woman  derives  no  advantage  from  the  kindly  open- 
ing of  the  OS  uteri,  or  long-looked-for  yielding  of  the  external 
parts,  as  she  is  now  deprived  of  that  energy,  so  necessary  to 
profit  by  these  changes.  It  is  in  vain  to  give  stimulants,  or  waste 
important  time  in  waiting  for  the  restoration  of  uterine  power — 
we  should,  however,  try  the  ergot ;  and,  should  this  not  renew 
the  uterine  forces,  we  must  turn,  provided  the  uterus  is  sufficient- 
ly relaxed,  the  membranes  entire,  or  the  waters  but  recently  ex- 
pended, and  the  head  of  the  child  still  enveloped  in  the  uterus. 
If  the  head  has  left  the  uterus,  or  occupies  the  lower  strait,  and 
is  not  easily  movable  in  the  pelvis,  we  must  use  the  forceps. 

728.  I  have  been  obliged,  under  the  head  of  "  Exhaustion,"  to 
give  examples  that  were  not  in  strict  conformity  with  the  subject 
in  question;  namely,  where  ''a  natural  labour  was  complicated, 
and  required  manual  assistance."  But  they  are  of  an  important 
character,  and  cannot  perhaps  be  classed  better,  under  any  other 
head.  Hitherto,  so  far  at  least  as  I  know,  every  species  of  inertia 
has  been  treated  in  the  same  manner;  the  distinction  I  have  made, 
I  think,  deserves  attention. 

Sect.  XII. — 12.  Hxinorrhage  from  other   Parts  than   the 
Uterus. 

729.  It  sometimes  happens,  though  rarely,  that  a  bleeding  of  j 
an  exhausting  kind,  as  from  the  stomach,  bowels,  or  lungs  may 


RULES  FOR  CONDUCTING  A  PRETERNATURAL  LABOUR.   265 

oblige  us  to  finish  a  labour  artificially,  that  might  have  terminated 
naturally,  without  such  an  accident.  When  a  bleeding  accom- 
panies labour,  which  if  too  long  continued  would  exhaust  the  pa- 
tient, we  should  inquire,  first,  what  agency  the  labour  has,  in 
either  its  production  or  its  continuance;  and,  second,  how  far 
immediate  delivery  would  contribute  to  arrest  it.  If  we  are  satis- 
fied upon  these  points,  and  conclude,  that  the  only  chance  for  the 
woman,  is  delivery,  we  should  proceed  to  it,  without  farther 
loss  of  time.  We  should  turn,  when  the  uterus  is  dilated  or 
dilatable;  when  the  membranes  are  entire,  or  they  have  but 
lately  given  way — use  forceps  when  the  uterus  is  strongly  con- 
tracting on  the  body  of  the  child,  and  the  waters  long  expended; 
or  when  the  head  is  low  in  the  pelvis. 


CHAPTER  XVIII. 

RULES  FOR  CONDUCTING  A  PRETERNATURAL  LABOUR. 

730.  Under  this  head,  I  shall  only  consider  the  rules  proper 
for  conducting  a  preternatural  labour,  where  the  hand  alone  is 
sufficient  to  terminate  it,  or  will  enable  the  woman  to  deliver 
herself.  As  preternatural  presentations,  strictly  so  called,  have 
nothing  in  them  before  labour,  to  declare  their  nature,  we  cannot 
possibly  rely  upon  any  symptoms  to  point  them  out;  we  must 
therefore  depend  solely  upon  an  examination  per  vaginam,  to  sa- 
tisfy ourselves  of  their  presence:  but  as  we  cannot  always  deter- 
mine with  sufficient  certainty  the  exact  position  of  the  child,  un- 
til the  membranes  have  given  way,  it  is  necessary,  as  a  general 
rule,  to  wait  until  tiiis  take  place,  before  we  can  decide  on  the 
species  of  the  presentation. 

731.  In  the  accidental  preternatural  labour,  (651  et  seq.)  we 
must  determine  upon  the  necessity  of  interference,  according  to 
the  extent  or  severity  of  the  accident  which  may  complicate  it; 
and  not  exclusively  by  the  good  or  bad  position  of  the  child.  We 
therefore,  in  such  cases,  regulate  our  conduct  almost  exclusively, 
as  regards  delivery,  by  the  condition  of  the  os  uteri — should  it  be 
unfavourable  to  operating  from  the  smallness  of  its  opening,  or  its 

34 


266  POSITION  OF  THE  WOMAN  FOR  TURNING. 

rigidity,  we  must,  for  the  time  being,  abandon  the  idea  of  enter- 
ing it  to  turn,  or  to  effect  any  other  important  change  upon  the 
child,  as  it  would  require  a  force  that  would  be  wholly  incom- 
patible with  the  safety  of  the  woman,  or  the  preservation  of  the 
child.  In  the  mean  time  we  temporise  in  the  best  manner  the 
nature  of  the  accident  which  complicates  the  case  will  permit,  by 
prescribing  the  remedies  the  most  proper  for  the  moment;  or 
adopting  such  means,  as  may  best  suit  the  exigency ;  as  bleeding, 
opium,  injections,  &c.  (See  chapter  on  the  causes  which  may 
render  a  natural  labour  preternatural,  p.  232.)  But  on  the  con- 
trary, if  the  OS  uteri  offer  no  difficulty,  we  have  only  to  consider 
the  best  moment  to  act,  when  we  have  the  choice  in  our  power 
This  choice  must  be  governed  by  general,  as  well  as  particular 
rules;  before  however  entering  upon  either  of  these,  it  will  be  ne- 
cessary to  point  out  the  proper  position  of  the  woman,  that  both 
may  be  the  better  understood. 

Sect.  I. — Position  of  the  Woman  for  Turning,  and  the  gene- 
ral Mode  of  Operating. 

732.  When  necessity  obliges  us  to  terminate  a  labour,  either 
well,  or  ill  begun,  the  woman  should  be  so  placed  as  to  give  the 
least  possible  hinderance  to  the  manoeuvres  of  the  accoucheur — the 
propriety  of  this  direction  is  agreed  upon  by  all;  but  there  exists 
a  diversity  of  opinion,  what  that  position  is.  Some  recommend 
the  side ;  others  the  knees,  and  others  the  back.  The  latter,  has 
always  appeared  to  me  as  the  best  that  can  be  adopted,  for  either 
convenience  or  advantage;  I  therefore  constantly  direct  the  wo- 
man to  be  placed  upon  the  back,  so  as  to  give  the  greatest  possi- 
ble freedom  for  action.  This  position  should  be  made  as  com- 
fortable as  the  nature  of  things  will  permit;  I  therefore  order  the 
bed  to  be  made  in  the  following  manner: 

733.  1st.  A  mattrass,  if  at  hand,  must  be  placed  so  as  to  reach 
to  the  very  edge  of  the  bedstead,  that  it  may  prevent  the  woman 
from  being  injured  by  its  hardness;  2d.  The  mattrass  must  be 
covered  with  a  folded  blanket,  or  sheet,  that  it  may  receive  no 
injury  from  the  discharges;  3d.  Two  chairs  should  be  placed  at 
a  proper  distance  apart,  to  support  the  feet  of  the  patient;  4th. 
The  feet  and  knees  are  to  be  steadied  by  an  attendant  sitting  on 
each  chair ;  5th.  An  old  rug,  blanket,  piece  of  carpet,  or  oil-cloth, 
should  be  spread  upon  the  floor,  immediately  below  where  the 


POSITION  OP  THE  WOMAN  FOR  TURNING.  267 

patient  will  be  placed,  to  secure  the  floor  from  being  soiled  by  the 
discharges;  6th.  A  pot  or  basin  should  be  at  hand,  that  it  may  be 
placed  upon  the  floor  below  the  patient,  to  receive  whatever  may 
drain  from  her,  after  she  is  fixed  upon  the  bed  for  delivery;  7th. 
The  patient  must  be  laid  upon  the  mattrass  horizontally,  with 
her  lower  extremities  over  the  edge  of  the  bed;  so  as  to  leave  the 
perineum  and  coccyx  free,  of  the  margin  of  the  bedstead;  8th. 
She  should  be  covered,  to  be  protected  against  cold,  as  well  as  to 
comply  with  the  rules  of  decency — so  much  regards  the  patient. 
On  the  part  of  the  operator,  the  following  rules  are  to  be  observ- 
ed; 1st.  All  parade  should  be  especially  avoided,  as  well  as  all 
formidable  preparations;  the  idea  sliould  never  be  given  that  the 
operation  in  question,  is  one  of  difficulty  or  hazard;  2d.  If  with- 
in command,  he  should  put  on,  after  he  has  taken  off' his  coat,  a 
loose  bed-gown  with  large  sleeves;  these  he  must  slip  up,  when 
on  the  point  of  operating;  this  will  prevent  the  exposure  of  the 
bare  arms,  which  are  always  unsightly  both  to  the  patient,  and  the 
bystanders;  especially  after  operating;  4th.  A  folded  sheet  should 
be  at  hand,  that  it  may  be  thrown  over  the  lap  of  the  operator  if 
he  sit;  but  I  have  ever  found  it  more  convenient  to  kneel  upon 
a  pillow;  which  position  I  would  recommend;  especially  if  the 
bedstead  be  low;  5th.  The  hand  should  be  lubricated  with  lard  or 
fresh  butter,  as  well  as  the  vagina,  and  external  parts  of  the  wo- 
man, before  an  attempt  be  made  to  pass  the  hand;  6th.  The  time 
of  pain  should  be  chosen  to  introduce  the  hand;  which  is  to  be 
made  into  a  conical  form,  that  it  may  enter,  and  dilate  the  vagina 
the  more  certainly,  and  gradually;  7th.  After  the  hand  is  in  the 
vagina,  the  absence  of  pain  should  be  chosen,  to  pass  it  into  the 
uterus;  8th.  The  hand  should  be  passed  in  the  most  gentle  and 
gradual  manner,  that  as  little  pain  may  be  given  as  circumstances 
will  permit,  as  well  as  to  not  provoke  untimely  contractions  of 
the  uterus ;  9th.  If  the  hand  become  much  cramped  or  fatigued, 
it  must  be  withdrawn,  that  it  may  recover;  10th.  The  operator 
will  be  much  aided,  while  searching  for  the  feet,  and  in  bringing 
them  down,  by  making  the  other  hand  fix  the  uterus,  by  a  gentle, 
yet  sufficiently  firm  pressure,  from  time  to  time,  externally  upon 
its  fundus  ;  thus  giving  advantages  to  the  hand  within,  that  could 
not  be  procured  without  it;  11th.  A  proper  selection  of  the  hand 
that  is  to  enter  the  uterus  must  be  made  ;  either,  not  being  equal- 
ly proper  in  all  cases;  I2th.  The  hand  should  be  passed  immedi- 
ately to  that  part  of  the  uterus,  where  the  feet  are  expected  to 


268  POSITION  OF  THE  WOMAN  FOR  TURNING. 

be;  and  this  must  be  determined  by  the  presentation,  or  situation 
of  the  child. 

734.  When  the  operator  has  gained  the  feet,  he  should,  1st. 
Grasp  them  firmly  with  the  hand,  but  should  always,  in  doing 
this,  place  a  finger  between  them,  to  prevent  injury,  from  com- 
pression; 2d.  When  practicable,  both  feet  should  be  acted  upon 
at  the  same  time:  3d.  Though  sometimes  practicable,  nay  easy 
occasionally,  to  deliver  by  one  foot,  it  should  never  be  done  but 
from  downright  necessity ;  and  this  can  occur  but  rarely  ;*  4th. 
In-  bringing  down  the  feet,  they  should  be  conducted  in  such 
manner  as  will  make  the  toes  constantly  look  towards  the  abdo- 
men of  the  child;  or,  in  other  words,  make  them  pass  as  it  were 
over  the  face ;  this  rule  is  most  important,  and  should  never  be 
neglected,  if  we  have  any  regard  for  the  vSafety  of  either  mother 
or  child  ;  for  if  infringed,  the  mother  may  suffer  a  laceration  of 
the  uterus,  and  the  child  certain  death,  by  an  injury  done  to  the 
spinal  marrow;  5th.  Should  it  only  be  practicable  to  bring  one 
foot  to  the  entrance  of  the  vagina,  let  it  be  secured  by  a  fillet, 
while  search  is  made  for  the  other;  6th.  No  attempt  should  be 
made  to  turn  the  child  during  a  pain,  lest  the  uterus  sufier  lace- 
ration; 7th.  But  after  the  feet  are  without,  every  advantage  should 
be  taken  of  pain,  if  it  exist,  to  facilitate  the  delivery.  8th.  The 
whole  act  of  turning  should  be  considered  as  one  of  necessity, 
rather  than  of  choice ;  therefore,  where  it  is  proper  to  attempt 
it,  it  is,  I  believe,  always  proper  to  finish  it,  and  not  to  trust 
the  farther  delivery  of  the  child  to  the  powers  of  nature,  as  some 
have  recommended;  9th.  The  operation  of  turning  should  be 
performed  slowly,  and  steadily;  especially,  if  it  be  attempted  in 
the  uncontracted  uterus,  or  immediately  after  the  evacuation  of 
the  waters  ;t  10th.  Difficulty  is  frequently  experienced  in 
bringing  down  the  breech,  when  the  feet  are  in  the  vagi- 
na, owing  to  the  head  sinking  in  part,  into  the  superior  strait; 
when   this  is  the   case,  the  head   should  be  raised,  while   the 

*  In  order  that  the  rule,  dthjfpar.  734,)  may  be  rigidly  observed,  it  will  be 
proper  to  observe,  that  in  complying'  with  rule  2d,  it  is  necessary  sometimes  to 
draw  a  little  stronger  upon  one  of  the  legs  of  the  child  than  the  other;  the  cases 
where  this  is  important,  will  be  readily  distinguished  by  the  operator  durijjg 
the  turning. 

f  This  rule  should  never  be  violated,  as  the  too  sudden  emptying  of  the  ute- 
rus may  occasion  accidents,  of  a  serious  kind;  as,  inversion  of  this  organ,  or 
severe  haemorrhage. 


POSITION  OF  THE  WOMAN  FOR  TURNING.  269 

feet  are  drawn  downward  ;  this  is  easily  managed,  by  applying 
the  thumb  against  the  forehead  of  the  child,  and  forcing  it  up- 
ward, while  the  fingers  which  are  grasping  the  feet  are  made  to 
draw  them  downwards;*  11th.  When  but  one  foot  can  be  seized 
at  a  time,  care  should  be  taken  that  it  belong  to  the  side  which 
the  hand  has  passed  over;  otherwise,  a  severe  twist  will  be  given 
to  the  body  of  the  child,  and  most  probably  defeat  the  attempt 
to  bring  it  down;  12th.  The  feet  should  be  brought  through  the 
external  parts  in  such  manner,  as  will  place  the  toes  towards  the 
anus  of  the  mother;  and  when  the  legs  are  delivered  as  far  as  the 
knees,  they  should  be  wrapped  in  a  piece  of  dry  cloth,  and  the 
thighs  taken  hold  of  with  the  same,  and  gently  drawn  down- 
wards until  the  nates  are  entirely  without;  the  hips  should  then 
be  taken  hold  of,  and  the  abdomen  drawn  through,  until  the  um- 
bilicus appears;  13th.  When  the  umbilicus  is  exposed,  a  loop  of 
the  cord  should  be  drawn  without  the  vulva,  that  it  may  not  be 
injured  by  being  too  severely  put  upon  the  stretch ;  to  do  this  in 
the  best  manner,  a  couple  of  fingers  should  be  slid  along  the  cord 
two  or  three  inches,  and  the  part  of  the  cord  above  the  fingers 
should  be  gently  pulled  by  the  upper  finger,  while  the  portion  of 
cord  next  to  the  child  should  be  prevented  from  being  stretched, 
by  pressing  it  and  retaining  it,  or  rather  pulling  it  towards  the 
umbilicus  by  the  thumb,  and  lower  finger;  while  the  upper  fin- 
ger draws  down  a  portion  of  it,  if  it  be  sufficiently  loose,  by 
stretching  itself  along  the  upper  part  of  the  cord:  14th.  If  the 
cord  do  not  descend,  or  cannot  be  made  to  do  so  by  gentle  means; 
and  if  there  be  reason  to  fear  it  will  sufier,  if  further  stretched,  it 
is  thought  best  to  cut  the  cord  ;  Baudelocque  says,  without  ap- 
plying a  ligature,  but  I  should  think  it  best  to  apply  one;  15th. 
When  the  child  is  freed  from  the  restraint  occasioned  by  the  cord, 
or  if  none  exist,  and  it  is  delivered  beyond  the  umbilicus,  it  should 
be  made  to  pass  through  the  arch  of  the  pubes  with  its  spine 
looking  towards,  or  pressing  against,  either  the  right  or  left  leg  of 
the  pubes,  that  the  head  may  enter  the  superior  strait  obliquely; 
this  must  be  done  by  a  little  turn  of  the  body,  if  it  does  not  place 
itself  in  this  situation  as  we  continue  our  tractions  downward. 
Little  difficulty  is  experienced  in  delivering  the  child  thus  far; 

*  Baudelocque,  par.  1302,  declares  this  double  action  to  be  impossible,  at  one 
and  the  same  time;  but  I  know  the  contrary,  from  frequent  experience;  and 
have  very  often  demonstrated  it  to  my  pupils  upon  the  machine. 


270  POSITION  OF  THE  WOMAN  FOR  TURNING. 

but  its  progress  is  interrujated  by  the  axillae  appearing  at  the  vul- 
va; 16lh.  When  the  axilla3  appear  at  the  os  externum,  the  one 
next  to  the  sacrum,  should  be  first  delivered  by  passing  a  finger 
or  two  upon  the  point  of  the  shoulder,  and  pressing  it  pretty 
firmly  downward,  and  then  tracing  the  arm  to  the  elbow; 
this  we  endeavour  to  bend,  by  pressing  it  on  its  internal  sur- 
face exactly  opposite  the  joint,  and  at  the  same  time,  urging 
it  downwards,  and  forward,  toward  the  face  of  the  child, 
where  it  will  almost  always  disengage  itself,  and  fall  into  the 
cavity  of  the  vagina;  from  whence,  it  is  easily  delivered  by  hook- 
ing it  forward,  with  the  point  of  the  finger — if  the  child  be  large, 
or  the  pelvis  small,  it  is  best  to  raise  up  the  body  of  the  child 
towards  the  abdomen  of  the  mother,  before  we  attempt  the  deli- 
very of  the  first  arm ;  if  the  pelvis  be  large,  or  the  child  small,  this 
is  not  necessary;  17th.  The  second  arm  is  now  to  be  delivered; 
this  is  almost  always  more  difficult  than  the  first,  and  sometimes 
extremely  so,  if  the  head  and  arm  are  both  engaged,  in  the  small 
diameter  of  the  superior  strait;  or  when  the  arm  has  passed  be- 
hind the  neck  of  the  child;  this  difficulty  however  is  overcome 
by  a  very  simple  process,  which  I  do  not  remember  to  have  seen 
recommended  by  any  one  for  this  purpose;  but  which  has  always, 
in  my  hands,  been  successful — this  is,  when  the  head  and  arm 
are  thus  situated,  to  turn  the  shoulder  of  that  arm,  to  that  side  of 
the  pelvis,  to  which  the  face  of  the  child  looks,  and  it  will  in- 
stantly become  disengaged ;  it  must  then  be  brought  down  as  di- 
rected for  the  other;  ISth.  If  the  head  should  be  too  high  to  de- 
liver the  shoulders  as  directed,  it  should  be  made  to  descend 
lower  in  the  pelvis,  by  pulling  at  the  body  provided  this  can  be 
done  safely  to  the  child  ;  if  this  cannot  be  done,  let  the  arms  be 
brought  down  first;  19th.  Should  the  head  be  so  low  as  to  press 
the  arms  strongly  against  the  margin  of  the  inferior  strait,  it  must 
be  pushed  backwards  and  upwards,  that  the  arms  may  have  more 
freedom.  When  the  arms  are  delivered,  there  remains  the  head 
to  be  disengaged;  for  the  liberation  of  which,  we  must  attend  to 
the  following  rules: 

735.  1st.  Before  any  attempt  be  made  to  extract  the  head,  its 
situation  should  be  determined  by  a  careful  examination  of  its 
position;  if  it  be  at  the  superior  strait,  the  face  must  be  at  one 
side,  that  the  great  diameter  of  the  superior  strait,  and  that  of 
the  head,  may  correspond:  if  it  be  not  in  this  position,  let  it  be 
so  placed ;  by  pressing  the  side  of  the  face  with  a  couple  of  fin- 


POSITION  OF  THE  WOMAN  FOR  TURNING.  271 

gers — when  thus  adjusted,  it  will  readily  descend  by  a  small  force 
applied  to  the  body,  but  this  must  be  in  the  direction  of  the  axis 
of  the  superior  strait;  2d.  If  the  head  be  at  the  inferior  strait, 
the  face  should  be  in  the  hollow  of  the  sacrum ;  if  not  thus  situa- 
ted, we  must  rectify  the  bad  position  by  pressing  against  the 
cheek,  and  carrying  the  face  to  that  place;  or  rather,  so  that  the 
face  shall  lie  upon  the  perinasum;  when  thus  placed,  the  great 
diameter  of  the  head,  and  that  of  the  lower  strait,  will  corres- 
pond; 3d.  The  body  of  the  child  must  now  be  carefully  sup- 
ported, by  passing  the  arm  beneath  its  body,  and  allowing  the 
legs  to  straddle  the  arm;  while  the  fore,  and  middle  fingers,  are 
passed  one  on  each  side  of  the  neck,  which  will  not  only  give 
support,  but  permit  a  firm  hold  when  tractive  force  is  required, 
to  deliver  the  head ;  4th.  When  the  head  is  in  this  situation,  it  is 
almost  always  without  the  uterus;  we  cannot  expect  therefore, 
any  aid  at  this  time  from  the  contractions  of  this  organ — the  wo- 
man must  now  be  solicited  to  employ  her  voluntary  powers  of 
bearing  dovvn,  that  too  much  force  need  not  be  employed,  by  act- 
ing on  the  body  of  the  child ;  5th.  To  co-operate  with  the  ex- 
ertions of  the  mother,  we  must  draw  the  body  of  the  child  nearly 
upward,  while  we  press  with  two  or  three  fingers  upon  the  occi- 
pital bone,  so  as  to  carry  it  downward,  and  disengage  it  from  be- 
hind the  pubes;  this  last  direction  I  consider  as  one  of  great  im- 
portance— by  attending  to  it,  I  have  secured  a  safety  to  the  child, 
which  would  have  been  lost  without  it;  6th.  Advantage  is  some- 
times gained  by  depressing  the  chin,  but  never  by  acting  upon 
it — the  object  in  depressing  the  chin  is,  to  prevent  its  hitching  in 
the  folds  of  the  vagina,  and  thus  creating  delay  and  difficulty. 

736.  It  will  be  readily  seen,  that  in  deliveries  of  this  kind, 
the  child  must  run  a  constant  risk,  whenever  there  is  the  least 
delay  to  the  delivery  of  the  head:  this  danger  arises  from,  1st. 
The  compression  of  the  umbilical  cord;  2d.  The  compression  of 
the  head  and  chest;  and  3d.  From  the  severe  extension,  the  neck 
doing  mischief  to  the  spinal  marrow.  With  a  view  to  remove 
these  latter  dangers  as  much  as  possible,  we  should  never  attempt 
to  deliver  the  body  of  the  child  rapidly  or  by  main  force;  the 
whole  of  this  difficult,  but  highly  important  process,  should  be 
conducted  coolly,  and  deliberately;  making  all  our  endeavours 
co-operate  with  those  of  the  uterus — pains  should  always  be 
waited  for,  though  they  may  be  far  apart;  as  much  of  the  mis- 
chief which  constantly  threatens  the  child,  is  removed  by  their 


272  FIKST  PRESENTATION. 

forwarding  it,  instead  of  its  being  the  effects  of  force  applied  to 
its  body.  Should  there  be  no  pain,  we  are  then  obliged  to  act 
without  them;  but  we  should  endeavour  to  imitate  them,  by- 
permitting  intervals  of  rest,  and  soliciting  the  efforts  of  the  wo- 
man. 

737.  In  the  hurry,  and  confusion  consequent  upon  a  delivery 
of  this  kind,  a  young  practitioner  is  apt  to  forget  the  useful  cau- 
tion of  not  turning  the  body  of  the  child  upon  the  head,  more 
than  the  spinal  marrow  will  bear;  but  this  important  direction 
must  not  be  lost  sight  of,  in  attempts  to  deliver  the  head  by  act- 
ing upon  the  body — I  once  saw,  in  the  hands  of  a  midwife,  two 
complete  turns  of  the  body  at  the  expense  of  the  neck;  I  need 
not  mention  the  result  of  such  ignorance. 


CHAPTER  XIX. 

THE  MODE  OF  OPERATING  IN  EACH  PARTICULAR    CASE    OF    HEAD 
PRESENTATION. 

738.  Having  in  the  preceding  pages  pretty  fully  detailed  the 
general  modes  of  conducting  the  operation  of  turning,  I  shall  now 
consider  it,  and  the  other  methods  to  be  pursued,  in  each  particu- 
lar presentation  of  the  head  when  rendered  preternatural  by  some 
accident  complicating  the  labour;  or  where  the  presentation  it- 
self, renders  interference  proper  and  necessary. 

Sect.  I. — First  Presentation. 

739.  I  have  already  given  the  characters  of  the  different  pre- 
sentations of  the  vertex;  therefore  I  shall  not  repeat  them.  I 
must  premise,  that  it  is  very  often  essential  to  the  success  of  the 
operating  of  turning,  that  a  proper  choice  be  made  of  the  hand. 
I  would  wish  to  impress  this  truth  upon  the  recollection  of  the 
inexperienced  practitioner;  and  as  the  rule  is  extremely  simple, 
there  is  no  excuse  for  its  neglect.  That  hand  should  be  employ- 
ed, the  palm  of  which  will  look  towards  the  face  of  the  child; 
therefore,  in  the  presentation  under  consideration,  it  will  be  the 
left  hand. 

740.  A  necessity  for  turning  existing,  the  woman  is  to  be  placed. 


SECOND  AND  THIRD  PRESENTATIONS.  273 

as  already  directed  for  preternatural  labours;  (732,  &c.)  and  the 
left  hand  properly  prepared,  must  be  introduced  into  the  vagina, 
with  the  thumb  looking  towards  the  symphysis  pubis;  the  hand 
must  be  placed,  so  as  to  grasp  the  head  with  the  fingers  on  one 
side,  and  the  thumb  upon  the  other — it  is  then  to  be  raised  in  the 
axis  of  the  superior  strait,  and  placed  in  the  left  iliac  fossa,  where 
it  must  be  retained  by  the  wrist  and  forearm,  while  the  fingers 
are  made  to  travel  over  the  left  side  of  the  child,  which  will  be 
towards  the  posterior  part  of  the  uterus,  until  they  get  possession 
of  the  feet — these  are  to  be  brought,  as  already  directed,  as  far 
as  the  middle  of  the  vagina;  when  thus  far,  it  frequently  happens, 
that  their  farther  progress  is  arrested  by  the  breech  not  descend- 
ing; and  the  breech  is  prevented  from  descending,  by  the  head 
having  slipped  from  the  iliac  fossa,  where  it  had  been  placed  in 
the  commencement  of  the  operation.  When  this  is  found  to  be 
the  case,  the  head  must  be  removed  by  the  compound  action  of 
the  hand  already  described;  (734,  10th)  when  this  is  done,  the 
breech  will  pass  into  the  superior  cavity  of  the  pelvis,  without 
farther  difficulty;  and  when  the  feet  appear  without  the  vulva, 
such  direction  should  be  given  to  the  breech,  as  will  place  the 
breast  of  the  child  towards  the  left  sacro-iliac  symphysis;  or,  in 
other  words,  obliquely  as  regards  the  superior  strait;  this  is  ef- 
fected by  acting  for  an  instant  only  upon  the  foot  that  is  imme- 
diately under  the  pubes,  and  finish  the  delivery  as  directed. 

Sect.  II. — Second  Presentation. 

741.  In  this  presentation  the  right  is  the  proper  hand,  for  the 
reason  already  assigned;  (739)  it  must  be  passed  up  until  the 
head  is  placed  into  the  right  iliac  fossa,  as  before  directed  for  the 
first  presentation;  the  right  side  of  the  child  must  be  passed  over ; 
the  feet  brouglit  down,  and  the  labour  finished  as  above. 

Sect.  III. —  Third  Presentation. 

742.  I  have  already  remarked,  that  this  presentation  may  be 
bad  in  itself,  and  render  a  labour  either  difficult,  or  preternatural, 
where  the  measurement  of  the  pelvis  is  rather  below  the  healthy 
standard;  or  the  head  excessively  large;  but  that  it  might  offer 
no  more  difficulty  than  the  first,  or  second,  where  there  obtained 
a  proper  relation  between  the  head  and  pelvis. 

743.  Either  hand  is  eligible  in  this  presentation,  as  will  be 
readily  perceived,  by  recalling  to  mind  the  rule  upon  this  subject 

35 


274  FOURTH  AND  FIFTH  PRESENTATIONS. 

— should  the  circumstances  accompanying  the  labour,  (be  they 
original,  or  accidental,)  oblige  us  to  have  recourse  to  turning,  we 
may  employ  that  hand,  of  which  we  have  the  greatest  command. 
Should  nothing  but  the  position  of  the  head  with  a  slight  diminu- 
tion of  capacity  in  the  antero-posterior  diameter  affect  the  labour 
we  may  sometimes  enable  the  woman  to  deliver  herself,  by  two 
or  three  fingers  applied  to  the  side  of  the  head,  so  as  to  carry  the 
vertex  towards  one  of  the  acetabula — to  the  right,  if  we  use  the 
right  hand,  and  to  the  left,  if  we  use  the  left — when  thus  placed, 
we  may  commit  the  termination  of  the  labour  to  the  natural  ef- 
forts; provided,  no  other  circumstance  complicate  the  labour. 

744.  Should  this  mal-position  of  the  head  not  be  discovered 
in  time;  and  the  uterus  be  contracted  firmly  on  the  body  of  the 
child,  the  fingers,  (as  directed  above,)  will  not  be  sufficient  for 
the  removal  of  the  occiput  from  over  the  pubes;  we  must,  in  this 
case,  introduce  either  hand  so  that  the  palm  will  look  upwards  in 
the  pelvis,  and  then  take  hold  of  the  head,  as  already  directed  it 
should  be  seized;  raise  it  in  the  direction  of  the  axis  of  the  uterus, 
and  when  a  little  freed  from  the  superior  strait,  turn  the  face  to 
the  side,  contrary  to  the  name  of  the  hand  employed;  then  trust 
to  the  powers  of  the  woman,  for  the  rest,  provided  these  appear 
sufficiently  efficient. 

745.  When  from  the  nature  of  the  case,  we  are  obliged  to  turn, 
we  carry  up  the  head,  and  give  it  the  turn  ji>st  mentioned;  and 
where  practicable,  make  the  shoulders  take  the  same  course;  the 
hand  will  point  out  the  side  to  which  the  face  must  be  turned; 
then  finish  the  delivery,  as  if  we  had  interfered  with  a  first  or 
second  presentation.  If  we  cannot  change  the  shoulders  by  act- 
ing immediately  upon  them,  we  may  give  the  proper  turn  by 
pulling  for  a  little  while  upon  the  right  leg,  if  the  face  is  turned 
to  the  left  side,  and  upon  the  left,  if  turned  to  the  right  side. 

Sect.  IV. — Fourth  and  Fifth  Presentations. 

746.  These  presentations,  in  consequence  of  the  forehead 
coming  under  the  arch  of  the  pubes,  are  always  more  painful  and 
tedious,  (creteris  paribus,)  than  where  the  vertex  offers  to  this 
part;  but  in  a  vvell-formed  pelvis,  unless  some  accident  complicate 
the  labour,  we  are  seldom  or  never  obliged  to  turn  for  these  posi- 
tions alone.  Should,  however,  any  circumstance  render  it  neces- 
sary, we  may  turn  in  these  cases,  with  as  much  facility  as  if  they 
were  the  first  and  second  vertex  presentations:  and  we  conduct 


SIXTH  PRESENTATION.  275 

the  process  precisely  in  the  same  manner;  that  is,  in  the  fourth, 
the  rules  for  turning  are  exactly  the  same  as  has  been  already 
directed  for  the  second  presentation,  and  in  the  fifth  it  is  con- 
ducted as  if  it  were  the  first — it  is  important,  in  these  cases,  that 
the  leg  which  offers  under  the  pubes  should  be  more  acted  upon 
than  the  other,  that  the  breech  may  take  a  proper  position  in  the 
superior  strait. 

Sect.  V. — Sixth  Presentation. 

747.  I  believe  it  best  in  this  presentation  to  turn,  if  the  head 
and  pelvis  have  but  their  ordinary  relations;  and  most  certainly 
so,  if  the  latter  is  a  little  contracted,  or  the  head  of  more  than 
ordinary  size;  provided  we  are  called  early,  and  can  have  the 
advantage  of  the  opening  of  the  membranes;  or  if  they  have  been 
but  recently  discharged.  If  the  head  be  small,  it  will  come  along 
without  much  difficulty;  and  if  but  very  little  smaller  than  the 
pelvis,  advantages  might  be  derived  from  turning  the  occiput 
from  the  projection  of  the  sacrum,  as  recommended  by  Baude- 
locque,  and  as  once  practised  by  myself,  (see  646;)  but  this  pre- 
sentation so  rarely  occurs,  that  almost  all  I  can  say  upon  the  best 
mode  of  treating  it,  is  derived  from  analogy  and  reasoning.  After 
the  head  has  passed  the  superior  strait,  it  can  offer  no  greater 
difficulties  than  the  fourth  or  fifth  presentation;  but  like  these, 
it  may  require  the  application  of  the  forceps;  for,  if  the  waters 
be  long  drained  ofi,  and  the  uterus  strongly  contracted  on  the 
child,  turning  would  be  extremely  difficult,  if  not  impracticable; 
as  happened  in  the  case  I  mentioned,  (646,)  having  succeeded,  by 
turning  the  occiput. 

748.  When  turning  is  attempted  in  this  case,  either  hand  may 
be  employed  at  the  option  of  the  operator;  the  head  must  be 
seized  as  directed  for  the  third  presentation,  and  converted  into 
the  fourth  or  fifth.  Baudelocque  recommends  it  being  reduced  to 
the  first  or  second;  I  sincerely  believe  this  to  be  impracticable; 
I  am  certain  it  cannot  be  done  if  the  waters  have  been  long  eva- 
cuated ;  and  if  it  have  succeeded,  it  must  be  at  the  moment  they 
have  expended  themselves,  and  while  the  head  yet  enjoyed  free- 
dom at  the  superior  strait.  The  turning  must  be  finished,  as  if 
the  head  originally  presented  in  either  of  these  positions. 

749.  Having  spoken  of  the  modes  of  terminating  preternatural 
labours  where  the  hand  alone  was  sufficient,  I  shall  now  proceed 


276  SIXTH  PRESENTATION. 

to  the  consideration  of  the  forceps  as  a  means,  where  the  hand  is 
not  capable  of  performing  it,  or  where  it  is  not  proper  to  employ- 
it — for  this  purpose,  I  shall  commence  with  a  general  considera- 
tion of  these  instruments;  and  afterwards  point  out  the  modes 
of  application,  in  each  particular  case;  this  will  bring  me  to  the 
third  part  of  the  work. 


PART  III. 


WHERE   IT   IS   NECESSARY  TO  USE    INSTRUMENTS    WHICH    DO 
NO  INJURY  TO  MOTHER  OR  CHILD. 


CHAPTER  XX. 

OF  THE  FORCEPS. 

750.  I  SHALL  not  unnecessarily  consume  time  in  tracing  the 
history  of  these  important,  but  too  frequently  abused  instruments; 
nor  point  out  the  alterations  which  caprice,  or  the  affectation  of 
improvement,  have  imposed  upon  them — I  shall  merely  declare 
my  preference  for  the  long  French,  or  the  Baudelocque  forceps. 
An  experience  of  many  years,  I  think,  justifies  this  choice;  the 
election  is  neither  hastily  nor  heedlessly  made;  I  think  I  have 
duly  weighed  the  merits  of  both  the  long  and  the  short  forceps, 
and  the  preponderance  is  in  favour  of  the  long.  In  making  this 
choice,  I  had  no  theory  to  support;  and  therefore,  had  no  preju- 
dices to  overcome;  my  sole  desire  was  to  determine  which  of  the 
two  would  best  answer  the  ends  for  which  they  are  designed — 
trials,  often  repeated,  have  led  to  the  conclusion,  that  there  is  no 
situation  of  the  head,  which  can  be  delivered  by  the  short  forceps, 
that  cannot,  with  at  least  equal  certainty  and  facility,  be  relieved 
by  the  long;  but  the  converse  of  this  does  not  obtain;  for  there 
are  situations  of  the  head,  which  cannot  be  relieved  by  the  short 
forceps;  but  to  which  the  long  are  every  way  competent;  this, 
in  my  estimation,  is  conclusive.     See  Plate  XIII. 

751.  I  shall  briefly  state  the  objections,  which  experience  has 
suggested,  against  the  short  forceps.  For  a  number  of  years  the 
short  were  the  only  forceps  I  employed:  and  I  only  abandoned 
them  from  a  conviction  of  their  inferiority  to  the  long.  First, 
they  can  only  be  employed  with  advantage,  when  the  head  oc- 
cupies the  lower  strait.     Second,  when  it  is  required  to  deliver 


278  OF  THE  FORCEPS. 

from  the  superior  strait,  or  above  it,  neither  their  length,  nor 
their  form,  will  permit  their  application;  we  are  then  obliged  to 
use  the  long;  but  the  converse  of  this  never  happens.*  Third, 
from  the  shape,  and  shortness  of  their  handles,  they  become  very- 
inconvenient  to  the  operator;  forbidding,  from  these  causes,  the 
application  of  a  sufficient  force,  to  overcome  the  resistance. 
Fourth,  their  mode  of  union  is  such,  as  to  render  them  extremely 
inconvenient  to  the  operator,  and  oftentimes  very  painful  to  the 
patient,  by  including  while  locking,  either  a  portion  of  the  soft 
parts,  or  some  of  the  capilli  of  the  pudendum;  thus  creating  a 
great  deal  of  pain. 

752.  It  is  however  insisted,  that  the  last  objection  can  always 
be  removed,  by  carefully  passing  the  finger  round  the  lock ;  but 
this  is  a  mistake — for  it  is  in  the  act  of  locking  that  this  inclusion 
takes  place.  Now,  it  is  certain,  that  the  locking  of  the  instru- 
ments requires  the  use  of  both  hands;  consequently,  we  cannot 
pass  a  finger  round  the  locking  portion,  so  as  to  extricate  the  soft 
parts,  or  capilli,  if  included,  or  prevent  them  from  insinuating 
themselves  between  the  joint;  as  the  hands,  and  of  course,  the 
fingers  are  otherwise  employed  at  this  moment.  It  is  true,  we 
may  search  for  the  included  part,  or  parts,  before  we  commence 
extracting;  but  to  relieve  the  soft  parts  would  require  the  sepa- 
ration of  the  blades  to  a  certain  extent,  and  this  without  any  se- 
curity that  it  will  not  happen  again,  when  the  handles  are  again 
pressed  together ;  and  the  capilli  can  only  be  relieved  with  cer- 
tainty, by  breaking  them,  which  would  be  painful,  or  by  cutting 
them,  which  is  not  altogether  decent. 

753.  In  favour  of  the  long,  I  may  state,  that  no  one  of  these 
objections  attaches  to  them;  they  can  be  used  in  any  position,  or 
distance  of  the  head  within  the  pelvis;  that  the  form  and  length 
of  their  handles,  give  great  and  decided  advantage  to  the  opera- 
tor; rendering  his  exertions  more  effective,  and  much  less  fatigu- 
ing; their  mode  of  union  obviates  the  very  serious  objection  urged 
against  the  short;  (751)  for  they  lock  without  the  vulva,  even 

•  Dr.  Davis  seems  to  entertain  similai"  notions  of  the  insufficiency  of  the 
short  forceps  in  certain  cases,  and  I  shall  avail  myself  of  his  observations  on 
this  point.  He  says,  "  What  I  wish  at  present  to  insist  on,  is  the  absolute  un- 
suitableness  of  the  instrument  known  in  this  country  by  the  name  of  the  short 
or  common  forceps,  for  the  relief  of  cases  of  impaction,  from  disproportionate 
size  of  the  foetal  head  within  the  pelvis,  on  account  of  a  general  deficiency  of 
space  within  its  cavity." — {Ekm,  Oper,  Med.  p.  141.) 


RULES  WHICH  REGARD  THE  POSITION  OP  THE  WOMAN.      279 

when  the  head  is  high:  and  remote  from  it,  in  lower  positions — 
besides,  they  unite  in  themselves  the  forceps,  the  lever,  and  the 
blunt  hook. 

Sect.  I. — General  Rules  for  the  Use  of  the  Forceps. 

754.  We  may  divide  the  general  rules  for  the  use  of  forceps, 
into,  a.  Those  which  regard  the  position  of  the  woman,  b. 
Those  which  respect  the  uterus  and  soft  parts,  c.  Those  which 
refer  to  the  application  of  the  instruments,  and  their  action  on 
the  child's  head  ;  and  d.  The  mode  of  acting,  after  they  are 
applied. 

a. —  Those  ivhich  Regard  the  Position  of  the  Woman. 

755.  Position  is  every  way  important  to  the  successful  applica- 
tion of  the  forceps;  but  as  regards  the  particular  situation  of  the 
woman,  there  is  a  diversity  of  opinion,  between  the  British,  and 
Continental  practitioners — and,  indeed,  the  same  may  be  said  of 
the  different  accoucheurs  in  our  own  country ;  this  depends  yery 
much  upon  the  school  in  which  they  have  been  educated,  or  the 
authority  they  are  in  the  habit  of  following.  The  British  practi- 
tioner almost  invariably  directs  the  patient  to  be  placed  upon  her 
side,  with  her  hips  near  the  edge  of  the  bed  ;*  while  the  Conti- 
nental accoucheur,  has  her  placed  upon  her  back.t  It  is,  perhaps, 
not  very  difficult  to  explain  the  cause  of  this  difference — the  Bri- 
tish praciitioner  never,  or  but  very  rarely  since  the  days  of  the 
well-instructed  and  judicious  Smellie,  attempts  to  deliver  the  head 
from  the  superior  strait;  while  many  of  the  Continental  accouch- 
eurs do — in  the  first,  the  lateral  position  of  the  woman  is  perhaps 
as  proper  as  any;  but  in  the  second,  it  would  be  impossible  to 
deliver  from  the  superior  strait;  now,  as  the  position  of  the  back 
enables  the  practitioner  to  deliver  from  any  part  of  the  pelvis,  it 
should  always,  I  think,  be  preferred  ;  especially  as  the  relative 
situations  of  the  head,  and  pelvis,  will  be  better  understood  by 
the  young  practitioner  ;  for  he  will  have  the  symphysis  pubis  as 
a  mark,  by  which  he  can  determine  every  other  part  of  the  pel- 
vis; this  he  cannot  so  exactly  do,  when  the  patient  is  on  her  side. 

756.  Therefore,  when  practicable,  I  would  recommend  she 
should  be  placed  upon  her  back,  as  directed  for  turning  (733,  &.c.) 
both  for  convenience  and  safety.     I  say  when  practicable;  for  it 

*  Denman,  &c.  |  See  Baudelocque,  &c. 


2S0         THE  CONDITION  OF  THE  UTERUS  AND  SOFT  PARTS. 

is  not  always  so  ;  since,  in  cases  of  extreme  exhaustion,  of  flood- 
ing, of  convulsions,  &c.  we  sometimes  cannot  move  the  patient  to 
be  thus  placed;  but  we  can  always  turn  her  upon  her  side  ;  or  if 
the  head  be  very  low,  and  the  patient  is  on  her  back  when  inter- 
ference is  necessary,  she  may  remain  so  ;  but  when  we  can  com- 
mand position,  I  repeat,  I  prefer  placing  the  woman  upon  her 
back,  with  her  perineum  free  over  the  edge  of  the  bed. 

757.  Before  we  proceed  to  the  use  of  the  instruments,  we 
should  apprize  the  friends  and  the  patient,  of  their  necessity — it 
rarely  happens,  that  tbe  patient  is  alarmed  at  this  alternative ; 
as  a  very  short  explanation  of  the  mode  of  action  of  the  forceps, 
always  satisfies  her ;  for  we  have  only  to  say,  that  the  natural 
powers  are  insufficient ;  that  the  situation  of  the  child  requires 
immediate  relief,  as  its  longer  continuance  in  the  passage  might 
be  fatal.  But  at  the  same  time,  we  must  not  give  any  positive 
assurance  of  its  safety  by  the  operation;  though  its  chance  should 
be  represented  as  increased.  Cause  her  to  think  the  instruments 
an  artificial  pair  of  hands,  whose  use  is  to  clasp  the  head  of  the 
child,  and  thus  promote  its  delivery;  and  she  becomes  at  once 
reconciled  to  their  employment. 

758.  We  should  take  care,  before  we  use  the  forceps,  that  the 
bladder  be  discharged  of  its  urine,  either  by  the  catheter,  or  by  a 
voluntary  effort  of  the  patient ;  and  that  the  rectum  be  unloaded 
by  a  simple  injection,  if  it  has  not  been  emptied  a  short  time  be- 
fore ;  also  that  the  vagina,  external  parts,  and  instruments,  be  well 
lubricated  with  hog's  lard,  or  soft  pomatum;  and  the  latter  warm- 
ed by  being  placed  in  warm  water.* 

b. —  The  condition  of  the  Uterus  and  Soft  Parts. 

759.  The  forceps  should  never  be  employed,  whatever  may  be 
the  emergency,  before  the  os  uteri  ■^.>  sufficiently  dilated,  or  readily 
dilatable,  and  the  membranes  ruptured.  Were  w^e  to  attempt 
their  application  before  this  period,  we  should  do  much  mischief; 
if  not  altogether  be  foiled  in  our  enterprise.  We  must,  therefore, 
wait  until  this  has  taken  place;  but  we  should  endeavour  to  pro- 
mote this  condition  by  every  means,  which  may  be  compatible 
with  the  existing  situation  of  the  woman.     This  may  sometimes 

*  In  warming  the  forceps,  care  should  be  taken  that  the  water  isnottoo  hot; 
it  will  be  sufficiently  warm,  if  the  hand  can  just  be  borne  in  it.  It  is  proper, 
even  in  warm  weather,  to  observe  the  precaution  of  wai-ming  the  forceps. 


APPLICATION,  AND  MODE  OF  ACTION  OP  THE  FOllCEPS.       281 

be  by  blood-letting,  as  in  convulsions,  &c.  or  by  laudanum,  as  in 
certain  kinds  of  exhaustion,  &c.  but  never  by  force.  We  are  told 
that  the  application  of  the  belladonna  to  the  os  uteri  has  been 
useful  for  this  purpose;  but  of  this  I  have  no  experietice.  Chau- 
sier  recommends  the  extract  of  the  belladonna,  with  great  confi- 
dence, in  cases  of  rigidity  of  the  os  uteri.  He  causes  it  to  be  in- 
corporated with  some  soft  ointment,  and  applied  by  means  of  a 
particular  syringe  to  the  circle  of  the  uterine  orifice.  In  half  an 
hour,  or  in  forty  minutes  at  farthest,  after  its  application,  he  de- 
clares, the  orifice  of  the  uterus  becomes  so  much  relaxed,  as  to 
offer  no  farther  resistance  to  the  efforts  of  the  body  of  the  fun- 
dus.— [Co)isiderdtions  sur  les  Convulsions  qui  Attaquent,  les 
Femmes  Encientes,  p.  22.)* 

760.  Should  the  membranes  be  entire  at  the  time  we  are  about 
to  operate,  we  may  very  readily  effect  their  rupture  by  artificial 
means;  but  this  should  not  be  done  until  the  os  uteri  is  in  a  proper 
condition  for  the  operation.  It  would  be  desirable,  that  the  ex- 
ternal parts  should  also  be  disposed  to  yield  readily  before  we 
commence;  but  this  is  of  much  less  importance  than  the  relaxa- 
tion of  the  os  uteri;  for  these  may  be  dilated  gradually  by  the  in- 
struments, or  made  to  yield  by  the  application  of  lard  or  soft  po- 
matum. 

c. — Jljii^Ucation^  and  mode  of  Jlction  of  the  Forceps. 

761.  The  proper  application  of  the  forceps,  in  each  situation  of 
the  head,  has  ever  been  considered  as  an  achievement  of  difficulty. 
It  requires  a  complete  knowledge  of  the  various  divisions  of  the 
pelvis;  an  acquaintance  with  the  construction  of  the  child's  head; 
and  the  mode  of  ascertaining  its  precise  situation,  in  the  cavity 
which  contains  it,  &c..  It  will  also  be  necessary  to  the  success 
of  the  operation,  that  the  practitioner  understands  the  construc- 
tion and  mode  of  action  of  his  instruments,  and  have  by  practice 
acquired  some  facility  in  placing  them.  It  has  been  considered 
by  Dr.  Denman,  as  uncertain,  whether  the  art  of  midwifery  has 
been  benefited,  or  injured,  by  the  introduction  of  instruments  into 

*  Since  writing  the  above,  Dr.  James  and  myself  had  a  case  of  the  most  rigid 
OS  uteri  either  had  ever  witnessed.  In  this  case  we  ti-ied  the  belladonna,  with- 
out the  slightest  advantage.  We  perhaps  did  not  apply  it  as  effectually  as 
Chausier,  as  we  were  not  in  possession  of  his  syringe  for  this  purpose.  Should 
another  case  occur  in  which  I  should  think  it  advisable  to  employ  this  drug,  I 
would  introduce  it  by  means  of  a  sponge  well  saturated  with  the  extract — pre- 
viously reducing  its  tenacity. 
36 


282      APPLICATION,  AND  MODE  OF  ACTION  OP  THE  FORCEPS. 

its  practice.*  That  much  mischief  has  been  done  by  the  ill-judged, 
and  worse-conducted  application  of  the  forceps,  I  have  had  reason 
to  know;  but  the  abuse  or  wrong  use  of  a  thing,  by  no  means 
furnishes  a  logical  conclusion  against  its  proper  use.  Indeed  were 
we  to  admit  this  reasoning  in  almost  any  concern  of  human  life, 
we  should  have  a  most  reduced  catalogue  of  real  benefits;  and 
were  it  legitimate  to  urge  it  in  the  practice  of  physic,  or  surgery, 
we  should  scarcely  dare  to  prescribe  an  article  of  the  materia 
medica,  or  venture  to  employ  a  single  instrument,  of  the  very 
many  we  now  consider  essential  to  the  exercise  of  these  branches 
of  medical  science.  Yet  what  practitioner  would  give  up  opium, 
camphor,  mercury,  bark,  and  a  hundred  other  articles,  because 
quacks,  and  ill-instructed  people,  have  abused  them,  or  even  de- 
stroyed with  them  ?  or  who,  in  the  practice  of  physic,  would  throw 
aside  the  trephine,  the  scalpel,  the  gorget,  or  the  amputating 
knife,  because  either  of  these  instruments  in  the  hands  of  the  un- 
skilful, might  be  mischievous? 

762.  Let  those  who  are  to  practise  midwifery,  become  well  ac- 
quainted with  its  elements,  before  they  commence  it;  then  gra- 
dually proceed  to  the  exercise  of  the  more  difficult  operations 
connected  with  it,  and  the  clamour  against  the  use  of  forceps  will 
in  great  measure  cease,  because,  there  will  necessarily  be  less 
reason  for  complaint.  A  severe  probation  awaits  an  upright,  and 
conscientious  man,  upon  his  introduction  to  the  practice  of  mid- 
wifery; for,  if  he  be  such,  it  will  be  a  long  time  before  he  will 
dare  to  flatter  himself,  that  he  can  do  that  which  is  best  for  his 
patient:  and  until  he  can,  he  will  not  be  satisfied  with  himself — 
but  this  very  distrust  will,  very  probably,  lead  him  to  cultivate 
his  talents  by  constant  reading,  that  he  may  keep  pace  with  the 
improvements  in  his  profession,  and  seek  the  aid  of  those  better 
qualified  than  himself,  when  difficulty  presents  itself. 

763.  Much  of  the  embarrassment,  and  it  may  be  safely  added,  the 
risk,  in  the  application  of  the  forceps,  might  be  obviated  were 
every  gentleman,  during  his  medical  studies,  to  prepare  himself 
by  the  frequent  application  of  these  instruments  upon  the  machine 

*  I  am  convinced,  that  if  the  forceps  be  judiciously  employed,  the  lives  of  ve- 
ry many  children  may  be  saved;  and  that  the  death  of  the  mother  would  be  a 
rare  occurrence.  Dr.  Davis  declares,  •'  In  my  own  practice,  as  one  of  the  phy- 
sicians to  the  Maternity  Charity  of  London,  which  is  beyond  comparison,  the 
most  extensive  obstetric  institution  in  Europe,  I  have  tlie  satisfaction  of  being 
able  to  assert,  that  I  have  never  incurred  the  misfortune  of  losing  a  motlier  in 
consequence  of  a  forceps  operation." — {Elem.  Oper.  Mid.  p.  274.) 


APPLICATION,  AND  MODE  OP  ACTION  OF  THE  FORCEPS.  283 

under  all  the  various  conditions  the  head  may  offer  itself  within 
the  pelvis — but  I  am  sorry  to  say,  this  mode  of  acquiring  know- 
ledge, is  not  sufficiently  appreciated  by  those,  to  whom  it  would  be 
of  the  most  direct,  and  essential  service.  There  is  a  tact  in  every 
operation,  which  is  indispensable  to  its  well  performance,  and  suc- 
cess; but  this  can  only  be  acquired,  by  its  frequent  repetition — 
for  what  would  be  said  of  the  surgeon,  who  expected  to  acquire  a 
knowledge  of  the  anatomy  of  the  part  upon  which  he  was  about 
to  operate  by  dissecting  the  living  fibre,  for  the  first  time  in  his 
life?  or,  who  could  expect  a  man  to  apply  the  forceps  with  skill, 
the  first  time  he  attempted  it  upon  the  living  machine,  without  a 
previous  exercise  upon  the  artificial  one?  The  same  observations 
will  apply  to  turning. 

764.  But  it  would  be  unfair  to  charge  all  the  mischief  which 
has  followed  the  use  of  forceps,  to  the  ignorance  of  those  who 
have  employed  them;  or  to  the  action  of  the  instrument  itself — 
much  is  justly  attributable  to  the  views  which  many  celebrated 
men  have  taken  of  their  necessity,  or  utility,  as  well  as  to  the 
rules  they  have  laid  down  for  their  application.  In  many  in- 
stances, the  evils  which  appeared  to  follow  their  use  really  existed 
before  they  were  employed ;  but  which  might,  I  am  persuaded, 
in  many  cases  have  been  prevented,  had  a  timely  and  judicious 
use  been  made  of  them. 

765.  The  following  case,  which  is  every  way  in  point,  occur- 
red to  me  a  short  time  since:  A  lady  with  her  first  child,  felt 
slight  pains  for  several  hours  before  she  thought  it  necessary  to 
send  for  me.  The  pains  when  I  first  saw  her  were  pretty  fre- 
quent, but  not  very  protrusive;  the  external  parts  rather  rigid, 
the  OS  uteri  not  freely  dilated,  and  the  membranes  were  entire. 
After  waiting  two  hours,  the  pains  became  more  effective,  and 
the  head  soon  occupied  the  lower  strait — two  hours  more  were 
given,  at  the  end  of  which  time  the  vertex  was  about  to  emerge 
under  the  arch  of  the  pubes,  and  the  perineal  tumour  was  formed. 
The  pains  now  became  more  distant  and  less  forcing;  while  the 
external  parts  remained  rather  rigid,  but  not  obstinately  so.  The  er- 
got was  now  given  at  three  several  times,  but  without  producing  the 
slightest  increase  of  energy  in  the  contractions  of  the  uterus.  I 
now  proposed  the  forceps;— but  their  employment  was  obstinately 
resisted;  and  as  no  advantage  whatever  was  derived  from  the  delay, 
and  as  the  perinaeum  was  very  much,  and  permanently  distended, 
1  became  uneasy,  and  represented  as  forcibly  as  I  knew  how,  the 


284     APPLICATION,  AND  MODE  OP  ACTION  OP  THE  FORCEPS. 

necessity  of  immediate  delivery  by  the  forceps.  I  presented  for 
the  consideration  of  the  patient,  the  advantages  of  immediate  de- 
livery, and  the  probable  consequences  to  both  her  child  and  her- 
self, if  it  were  not  complied  with;  but  nothing  could  prevail  upon 
her  to  submit;  she  however  promised,  that  if  she  were  not  better 
in  another  hour,  she  would  comply  with  my  wishes.  This  hour 
like  the  six  preceding,  passed  away  without  the  hoped-for  advan- 
tage. She  now  consented  to  submit  to  anything  I  judged  proper 
for  her  relief.  But  I  thought  it  proper  before  I  applied  the  for- 
ceps, to  state  to  the  friends  my  fears,  that  serious  consequences 
might  follow  from  this  long  and  unavailing  delay,  though  the  de- 
livery could  be  easily  accomplished.  I  applied  the  instruments; 
and  in  less  than  fifteen  minutes  she  was  delivered,  contrary  to  ex- 
pectation, of  a  living  child  ;  and  also  contrary 'to  expectation,  the 
patient  appeared  to  be  very  well,  except  that  the  catheter  was 
employed  two  or  three  times  for  emptying  the  bladder.  On  the 
third  day  the  urine  was  discharged  by  voluntary  efforts,  and  every 
thing  seemed  to  promise  well,  except  a  burning  and  benumbing 
pain  that  was  felt  at  the  extremity  of  the  coccyx,  and  perinaeum: 
this  increased  so  much  as  to  require  anodynes  and  warm  poul- 
tices. About  the  eighth  day,  sloughing  of  the  perineum  com- 
menced, and  proceeded  down  to  the  sphincter  ani,  and  some  dis- 
tance up  the  vagina.  The  parts  have  healed  however  more  for- 
tunately than  could  at  first  have  been  expected;  the  perinseum 
almost  alone  having  suffered;  leaving  the  rectum  safe,  and  the 
vagina  without  serious  injury — the  case  now  resembles  a  lacera- 
ted perinseum.* 

766.  Dr.  Denman,  more  perhaps  than  any  other  man,  is  charge- 
able with  perpetuating  errors  in  the  use  of  the  forceps,  because, 
he  is  considered  the  highest  British  authority  upon  the  subject. 
In  his  attempt  at  precision,  he  has  created  confusion  ;  and,  in  his 
desire  to  generalize,  he  has  made  so  many  exceptions,  that  his 
Aphorisms  are  no  longer  rules.  The  necessity  for  using  the  for- 
ceps he  has  taken  principally  from  the  time  the  head  has  tarried 
at  tlie  lower  strait  or  passage,  and  the  condition  of  the  woman ;  with- 
out the  slightest  regard  to  circumstances,  which  may  complicate  the 
labour,  or  make  a  departure  from  the  rule  necessary  to  both  mo- 
ther and  child.  His  aversion  to  instruments  made  him  restrict 
their  powers  to  such  narrow  limits,  as  to  render  them  scarcely 

*  I  have  delivered  this  lady  safely  twice  since  the  above  case  occurred. 


APPLICATION,  AND  BFODE  OF  ACTION  OF  THE  FORCEPS.     285 

subservient  to  the  art ;  and  he  reduced  the  cases  proper  for  their 
application  to  so  few,  and  so  peculiar,  that  they  are  scarcely  to 
be  met  with,  that  they  iTiay  be  employed. 

767.  Thus  we  find  that  Dr.  Denman's  fourth  Aphorism  de- 
clares that  "the  intention  in  the  use  of  forceps  is,  to  preserve  the 
lives  of  both  mother  and  child:"  thus  far  good  ;  but  in  the  very 
next  sentence  he  says,  "but  the  necessity  of  using  them  must  be 
decided  by  the  circumstances  of  the  mother  only;"  that  is,  as  I 
understand  it,  and  as  I  believe  every  body  else,  means,  we  are  not 
to  deliver  with  a  view  to  save  the  child,  unless  something  threaten 
the  mother.  Is  not  this  sadly  and  improperly  limiting  the  utility 
of  the  forceps?  for  what  security  have  we,  when  danger  assails 
the  mother,  that  the  child  will  not  perish  before  we  are,  agree- 
ably to  Dr.  D.,  justified  in  delivering  it?  Let  us  again  suppose 
that  the  body  of  the  child  is  delivered,  and  that  the  head  cannot 
be  made  to  pass,  either  from  the  want  of  ordinary  power  on  the 
part  of  the  mother,  or  from  the  extraordinary  size  of  the  child's 
head  as  regards  the  pelvis;  are  we  to  permit  the  child  to  perish 
because  there  is  no  <' circumstance,"  that  is,  as  I  understand  it, 
no  danger  threatening  the  mother,  to  authorize  immediate  deli- 
very by  the  forceps,  though  he  just  expressly  declared  their 
"  intention"  is  to  save  the  lives  of  both? 

768.  His  fifth  Aphorism  declares,  "  it  is  meant  when  the  for- 
ceps are  used  to  supply  with  them  the  insufficiency,  or  the  want 
of  pains ;"  here  is  a  plain  and  positive  direction,  one  that  the 
common  sense  of  mankind  would  at  once  agree  to  be  sound  and 
proper;  one  that  would  justify  in  the  absence  of  sufficient,  or  ef- 
ficient pains,  the  employment  of  forceps  to  supply  the  deficiency 
of  the  natural  powers ;  but  all  this  prudent  and  well-tested  direc- 
tion is  destroyed  by  the  next  member  of  the  Aphorism;  namely, 
"  but  so  long  as  the  pains  continue,  we  have  reason  to  hope  they 
will  produce  their  effect,  and  shall  be  justified  in  waiting. 

769.  In  the  Lend.  Med.  and  Phys.  Jour.  Aug.  1825,  p.  157, 
I  am  indirectly  charged  with  misquoting  Dr.  D.'s  fifth  Aphorism, 
which  I  take  this  opportunity  to  disclaim.  I  quoted  from  an 
American  republication  of  the  Aphorisms,  and  agreeable  to  that, 
I  find  I  am  correct.  My  observations  on  these  Aphorisms  were 
made  more  than  tv/enty  years  ago;  and  if  there  be  a  discrepancy 
in  the  two  texts,  it  may  have  arisen  from  a  subsequent  change  in 
Dr.  D.'s  opinion  on  this  subject;  as  the  reviewer  quotes  from  the 


286      APPLICATION,  AND  MODE  OF  ACTION  OP  THE  FORCEPS. 

sixth  edition.*  The  additional  sentence,  '^with  any  degree  nf  vi- 
gour,'''' ahers  the  matter  little  or  none,  in  my  opinion — "  for  with 
any  degree  of  vigour,"  is  extremely  indefinite;  for  the  degree  of 
suffering  may  lead  to  the  helief  that  force  is  always  commensurate 
with  pain;  than  which  there  can  be  but  few  greater  mistakes;  espe- 
cially in  cases  like  those  under  consideration.  For  the  cases  in 
which  the  most  suffering  is  endured,  are  those  in  which  we  find 
labours  the  slowest.  Had  the  sentence  read,  "so  long  as  the  na- 
tural pains  continue  with  vigour,"  the  meaning  would  have  been 
clear ;  and  it  would  have  authorized  the  alternative  of  the  forceps, 
when  this  was  not  the  case.  As  it  stands,  even  in  the  reviewer's 
quotation,  I  am  persuaded,  every  inexperienced  practitioner  would 
feel  himself  justified  in  waiting  too  long. 

770.  I  must  still  insist,  that  if  this  Aphorism  have  any  mean- 
ing collectively,  it  forbids  the  use  of  the  forceps  so  long  as  there 
are  pains,  however  feeble  or  transitory  these  may  be,  or  however 
insuflBcient  for  the  end  proposed — the  value  of  pains  must  be  esti- 
mated by  their  power  upon  the  body  to  be  moved,  and  not  by  the 
degree  of  suffering  the  woman  may  endure.  But  let  it  be  recol- 
lected, that  beside  the  risk  the  child  runs  by  long  delay  in  the 
passage,  the  soft  parts  of  the  mother  are  suffering  from  the  long 
pressure  of  its  head  ;  subjecting  them  to  contusion,  inflammation, 
sloughing,  &c.  and  this  to  comply  with  a  prejudice  against  the 
proper  employment  of  the  forceps.  But  let  us  attend  to  what  Dr. 
Merriman,  one  of  the  most  zealous  admirers  of  Dr.  Denman,  says 
upon  this  subject.  He  was  called  to  the  aid  of  a  midwife  in  a  case 
where,  "  the  vertex  was  actually  protruding  through  the  os  ex- 
ternum," but  where  it  was  necessary  to  draw  off  the  urine  as 
the  woman  had  passed  none  for  many  hours — this  was  done,  but 
he  says,  "  on  passing  my  finger  into  the  vagina,  the  vagina  felt  so 
excessively  hot  and  burning,  as  convinced  me  that  the  delivery 
ought  not  to  be  trusted  to  the  efforts  of  nature,  but  that  the  child 
must  be  removed  with  all  proper  expedition,  or  otherwise,  there 
was  great  reason  to  apprehend  that  mortification  and  slough- 
ing of  the  vagina  ivould  ensue.''  He  accordingly  delivered  her 
with  the  forceps.  His  conduct  upon  this  occasion,  leads  him  to  the 
following  reflection:  "  It  is  laid  down  as  a  rule  in  practice,  and  it  is 


*  On  consulting  the  works  of  Dr.  D.  as  edited  by  Dr.  Francis,  I  find  the 
Aphorism  precisely  as  I  have  quoted  it;  and  Dr.  F.  declares,  he  has  publish- 
ed, from  the  last  edition,  corrected  by  the  author. 


APPLICATION,  AND  MODE  OF  ACTION  OP  THE  FORCEPS.      287 

one  of  those  rules  which,  being  founded  in  reason  and  experience, 
ought  not  lightly  to  be  deviated  from,  that  the  head  of  the  child 
should  be  in  a  situation  capable  of  being  delivered  by  the  forceps 
for  at  least  six  hours  before  they  are  had  recourse  to."  "  But  a 
rigid  observance  of  it  in  the  case  I  have  related,  would  have  proved 
highly  injurious,  if  not  fatal,  to  the  patient,  as  it  is  apparent,  that 
a  very  high  degree  of  inflammation  in  the  vagina,  and  parts  ad- 
jacent, was  just  upon  the  point  of  taking  place;  and  had  the  head 
of  the  child  been  suffered  to  remain  there  much  longer,  so  much 
inflammation  must  necessarily  come  on,  as  might  have  proved 
incontrollable."  In  this  case  the  head  was  "down  low  in  the 
pelvis,"  but  two  hours.  (Edinb.  Med.  and  Phys.  Jour,  for  1810.) 

771.  Dr.  Davis  also  relates  a  case  completely  illustrative  of  the 
point  I  have  attempted  to  enforce;  namely,  that  the  soft  parts 
of  the  mother  may,  by  the  long  delay  of  the  child's  head  in  the 
passage,  suffer  extensive,  and  irremediable  mischief.  In  the  case 
alluded  to,  the  patient  was  eighteen  hours  in  labour;  and,  "during 
no  stage  of  this  labour,  could  it  be  truly  asserted,  that  there  was 
not  some  progress  made. "  The  child  "  effected  its  transit  through 
the  pelvis,  certainly  in  the  midst  of  such  a  tempest  of  struggles, 
as  I  think  I  have  never  witnessed  on  any  other  occasion." 

772.  "The  patient  died  on  the  tenth  day  after  delivery." 
"On  inspecting  the  body  after  death,"  "the  cause  of  it  was  dis- 
covered to  have  been  a  large  abscess,  which  seemed  to  have  im- 
plicated all  the  structures  at  the  superior  part  of  the  cavity,  and 
towards  the  left  side  of  the  pelvis,  and  of  which  the  left  ovarium, 
probably  dangerously  contused  during  labour,  had  all  the  appear- 
ance of  being  the  nucleus."     (Elem.  Oper.  Mid.  p.  149.) 

773.  I  may  also  add,  that  the  head  of  the  child  itself  suffers 
very  severely  from  a  long-continued  pressure  upon  it;  producing 
extensive  extravasations  under  the  scalp,  as  well  as  sometimes 
abscess  of  this  part,  as  is  said  to  have  happened  to  a  child  that 
was  delivered  at  the  Royal  Maternity  Charity,  after  an  unusually 
tedious  and  painful  labour.  Baudelocque  gives  an  instance  of  the 
scalp  sloughing,  &c.  Vol.  III.  p.  161. 

774.  In  a  word,  experience  satisfactorily  proves,  that  much  risk, 
both  to  mother  and  child,  is  constantly  incurred,  by  the  head 
resting  too  long  upon  the  lining  of  the  pelvis.  Dr.  Davis  men- 
tions a  case,  (p.  156,)  where,  after  a  labour  of  this  kind,  '«the 
parietes  of  the  vagina"  were  much  swelled,  and  required  blood- 
letting and  leeching  to  subdue  it. 

775.  It  is  merely  intended,  by  what  is  just  said,  to  justify  the 


288      APPLICATION,  AND  MODE  OF  ACTION  OF  THE  FORCEPS, 

assertions  I  have  made  against  Dr.  Denman's  reluctance  to  em- 
ploy the  forceps,  and  not  a  critique  uj^on  his  Aphorisms — I  have 
offered  this  elsewhei'e.  See  "Essays  on  various  Subjects  con- 
nected with  Midwifery,"  by  the  Author. 

776.  Dr.  Osborn*  carries  this  reluctance  still  farther;  to  a  de- 
gree indeed  I  think  reprehensible,  as  it  seems  to  militate  against 
the  interests  of  society — but  he  has  not  done  equal  mischief  with 
Dr.  Denman;  because  Tiis  authority  was  not  equal.  He  requires, 
before  the  forceps  are  applied,  that  "  the  powers  of  life  be  exhaust- 
ed; all  capacity  for  farther  exertion  to  be  at  an  end;  and  that 
the  mind  be  as  much  depressed  as  the  body;  and  would  at  length 
both  sink  together  under  the  influence  of  such  continued  but  un- 
availing struggles,  unless  rescued  by  means  of  art." 

777.  I  v/ould  ask  with  what  prospect  of  success  could  art  in- 
terfere under  such  a  complication  of  evils?  the  woman  might  be 
delivered  but  what  would  be  her  after-condition,  or  that  of  the 
child  ? — why  one  would  be  subjected  to  all  the  evils  which  a  too 
long  delayed  delivery  would  produce,  if  not  death;  and  the  other, 
to  almost  inevitable  destruction. 

778.  Besides,  the  objections  against  the  forceps  are  founded 
upon  an  erroneous  estimate  of  their  tendency — that  they  have 
been  misused  I  admit;  and  so  has  almost  everything  else;  but 
that  they  have  been  productive  of  more  good  than  evil,  I  am  every 
way  persuaded.  As  regards  the  child,  there  can  be  no  hesitation  ; 
and  as  they  may  have  affected  the  mother,  I  am  certain  they  have 
been  highly  beneficial.  It  is  entirely  within  my  recollection, 
when  cases  similar  to  those,  now  treated  by  the  forceps,  were  re- 
lieved by  the  crotchet — the  child  a  certain  victim,  and  the  mo- 
ther a  probable. one.  In  the  year  1794,  I  was  sent  for  by  a  mid- 
wife, to  a  woman  who  had  been  six  and  thirty  hours  in  severe 
labour  with  her  first  child;  and  she  nearly  forty  years  of  age. 
Upon  examination,  the  posterior  fontanelle  was  found  at  the  left 
foramen  ovale;  the  pains  had  been  violent  and  frequent,  but  were 
now  feeble  and  transitory,  making  no  impression  upon  the  child. 
I  introduced  the  catheter,  and  discharged  a  large  quantity  of  wa- 
ter; then  applied  the  forceps,  and  soon  delivered  the  child.  So 
soon  as  it  was  born  it  began  to  cry;  and  when  liberated  from 
the  placenta,  I  handed  it  to  the  midwife,  who  received  it  with 
averted  face,  and  streaming  eyes.  I  inquired  of  her  what  had  so 
affected  her;  she  answered  by  pointing  to  the  child,  and  saying, 

*  Essays,  p.  45. 


APPLICATION,  AND  MODE  OP  ACTION  OP  THE  FORCEPS.     289 

"  who  with  any  feeling  could  help  it?  a  poor  child  to  be  alive  with 
its  head  open  !"  As  1  did  not  understand  her,  I  desired  she  would 
explain  herself;  this  she  did,  by  saying,  '^she  would  not  have 
cared  so  much,  had  it  been  killed  outright;  but  to  be  wounded  and 
alive,  was  truly  shocking!"  I  still  insisted  upon  further  explana- 
tion, as  I  yet  did  not  understand  her,  and  at  the  same  time  un- 
covering the  child,  asked  if  she  supposed  it  was  hurt,  and  if  she 
did  she  was  much  mistaken.  She  now  examined  the  child;  and 
to  her  utter  astonishment,  found  it  without  blemish.  She  then 
told  me,  she  would  have  sent  for  me  long  before,  but  for  the  hor- 
ror she  had  of  having  the  child's  head  opened;  which  she  assured 
me,  had  been  the  uniform  practice  upon  such  occasions,  when- 
ever she  had  sent  for  a  physician.  The  influence  of  this  case  up- 
on many  of  the  midwives  of  this  city,  procured  me  many  oppor- 
tunities of  applying  the  forceps.* 

779.  However  strongly  I  may  be  impressed  with  the  utility  of 
the  forceps,  I  should  not  feel  myself  warranted  to  use  them  as 
often  as  they  appear  to  be  in  Great  Britain,  and  on  the  continent 
of  Europe.  The  frequency  with  which  they  have  been  employed, 
in  some  instances  is  really  alarming;  and  I  had  like  to  have  said 

•  We  are  not  alone  in  making  a  charge  against  such  practitioners,  as  substi- 
tute the  crotchet  for  the  forceps,  and  with  similar  results  from  the  mutilation. 
Mr.  Dease  states  an  instance,  "  where  the  child  was  miserably  dragged  alive  in- 
to the  world,  with  a  great  part  of  the  brain  evacuated."  And  Dr.  Beatty  adds, 
'•  I  can  never  forget  a  scene  of  horror  to  which  I  was  a  witness  in  the  year  1800. 
I  was  called  upon  to  see  a  very  young  lady,  in  labour  of  her  first  child,  who 
was  under  the  care  of  one  of  the  oldest  and  most  eminent  practitioners  in  this 
city,  (since  dead) :  her  labour  was  most  violent,  which  she  bore  with  gi-eat  im- 
patience and  noise.  The  head  had  been  down  in  the  perinjeum  (he  said)  seve- 
ral hours;  I  pi-oposed  to  give  more  time  and  an  opiate,  not  doubting  the  pow- 
ers of  nature,  or  to  try  the  forceps,  which  he  dechned,  on  account  of  its  being 
her  first  child,  and  the  apprehension  he  entertained  of  her  being  exhausted;  and 
finally  he  opened  the  head.  The  operation,  as  it  always  does,  excited  extraor- 
dinary uterine  action,  and  before  it  was  well  concluded,  or  the  brain  evacuated, 
so  as  to  lessen  the  bulk  of  the  head,  the  child  was  propelled  into  the  world  alive 
and  crying.  The  old  gentleman  whose  patient  she  was,  was  a  person  of  very 
fine  feelings,  and  the  reader  may  imagine  his  sufTerings  on  viewing  the  effects 
of  a  rash  and  ill-judged  operation;  he  declared  no  earthly  consideration  should 
ever  induce  him  again  to  witness  the  application  of  the  perforator." 

Dr.  Beatty  also  remarks,  "  that  similar  instances  had  (he  understood)  occurred 
in  tills  city  (Dublin)  in  one  of  which  humanity  prompted  the  accoucheur  to 
plunge  the  child  into  a  vessel  of  water,  to  put  an  end  to  its  existence  and  cries." 
— Observations  on  the  use  of  instruments  in  cases  of  difficult  parturition  and  pro- 
tracted labour.  By  ,Tohn  Beatty,  M.  D.  &c.  flhtblin  Med.  Trans,  from  John- 
son? s  Mtdico-Chirur.  Review,  for  July,  1831.  J 
37 


290      APPLICATION,  AND  MODE  OP  ACTION  OF  THE   FORCEPS, 

must  have  been  too  often  unnecessary.*  In  my  own  proper  prac- 
tice, I  am  persuaded  I  have  not  employed  them  oftener  than  once 
in  three  hundred  and  fifty  cases ;  though  I  have  been  under  the 
necessity  of  using  them  very  frequently  in  the  practice  of  others. 

780.  I  must  not,  however,  be  understood  as  reflecting  upon  any 
individual,  by  the  last  remark — my  meaning  will  be  properly  un- 
derstood, when  I  state  that  some  years  ago,  the  practice  of  mid- 
wifery was  very  much  in  the  hands  of  females.  These  females 
were  not  competent  to  the  use  of  instruments;  consequently,  when 
they  were  necessary,  others  had  to  perform  this  duty  for  them ; 
it  fell  to  my  lot  to  do  much  of  this  business.  By  this  means  I 
have  seen  very  many  forceps  cases,  but  the  greater  part  of  these 
did  not  belong  to  me  as  original  cases. 

781.  But  let  me  ask,  what  is  to  be  feared  from  a  proper  appli- 
cation of  the  forceps?  is  their  mode  of  action,  when  well  direct- 
ed, such  as  to  do  injury  to  either  mother  or  child?  certainly  not 
— then  there  is  nothing  to  be  apprehended  from  their  structure, 
application,  and  mode  of  action,  since  necessarily,  they  neither 
cut  nor  contuse  mother  or  child  ;  neither  do  they  create  unneces- 
sary pain,  nor  inordinately  augment  that  which  may  be  present ; 
but  are  truly   calculated,  in  the   language  of  Dr.  Denman,  to 

•  The  following  statements  upon  the  subject  hi  question,  I  extract  from  Dr. 
Davis's  "  Elements  of  Operative  Midwifery." 

"  It  has  been  stated  by  Prof.  Baer,  (see  Medecina  Obstetrica,  p.  443,)  that  the 
forceps  have  been  used  in  the  practice  of  an  individual,  or  of  individuals,  whom, 
however,  he  has  not  chosen  to  name,  in  nearly  one  case  out  of  every  three  la- 
bours. Prof  Hag-en,  of  Berlin,  delivered  39  women  out  of  350,  or  1  in  9,  with 
forceps.  Prof.  Niigele,  of  Heidelburg,  reports,  that  in  the  practice  of  the  lying- 
in  institution  of  that  city,  for  the  year  1817  and  1818,  he  used  the  forceps  once 
in  53  cases.  Mr.  Burns  gives  the  proportion  of  Prof.  Nagele,  as  "very  much 
correspondhig  with  those  of  his  own  lists."  In  a  statement  of  presentations  at 
Le  Maison  d'Accouchments,  between  December,  1799,  and  May,  1809,flirnish- 
ed  by  the  late  M.  Baudelocque,  we  have  the  proportion  of  forceps  to  the  whole 
number  of  labours,  as  1  in  353.  Madame  Boivin,  1  in  212.  Madame  Lachapelle, 
1  in  166.  At  the  Obsteti-ic  School  of  Gottingen,  1  to  between  18  and  19.  At 
the  University  of  Stockholm,  1  in  every  100.  Dr.  Luders,  1  in  109.  M.  I.ob- 
stein,  20  times  in  712  cases.  Prof.  Boer,  of  Vienna,  once  in  238  labours.  In  Dr. 
Clarke's  Ab'stract  of  the  Dubhn  Lying-in  Hospital  registry,  It  is  stated,  tliatthe 
forceps  were  used  14  times  in  10,387  cases." 

Dr.  Davis  considers  the  proportion  of  1  in  53,  which  is  approved  by  Prof. 
Burns,  at  least  400  per  cent,  too  great;  and  is  of  opinion  that  the  forceps  are 
not  required  more  than  once  in  300,  or  at  most,  250  cases. 

Frcm  the  above  statements,  it  evidently  appears,  that  the  forceps,  in  the 
hands  of  some  practitioners,  have  been  most  wantonly  used,  and  in  those  of  some 
others,  as  improperly  withheld. 


APPLICATION,  AND  MODE  OF  ACTION  OF  THE  FORCEPS,      291 

supply  the  insufficiency,  or  want  of  labour-pains;  if  this  be  so, 
and  it  is  so  admitted  by  Dr.  D.  himself,  why  should  they  be  con- 
demned, because  they  may,  like  every  sublunary  good,  be 
abused? 

782.  Let  me  endeavour  to  strengthen  my  case,  by  considering, 
1st,  their  structure:  2d,  their  application:  and  3d,  their  mode  of 
action. 

783.  Their  structure  is  such  as  to  offer  the  greatest  possible 
security  to  the  child — the  breadth  of  the  clams  being  so  great,* 
as  to  prevent  any  partial  or  injurious  pressure;  and  the  excavat- 
ed diameter  between  the  blades,  even  when  the  handles  are 
pressed  pretty  closely,  will  permit  the  transversal  diameter  of  the 
head  of  a  child  of  ordinary  size  to  lie  between  them,  without  any 
or  with  very  little  inconvenience;  the  length  and  strength  of 
their  handles  are  such  as  to  permit  compression  wherever  that 
compression  may  be  necessary. 

784.  The  proper  application  of  the  forceps  consists  in  their 
complete  adaptation  to  the  sides  of  the  head  of  the  child,  or  as 
nearly  as  may  be  over  its  ears — when  fixed  upon  any  other  part 
of  the  head,  it  is  but  an  exception.  When  placed  as  just  sug- 
gested, the  head  is  embraced  in  the  direction  of  its  oblique  diame- 
ter, (82,)  and  the  small  diameter  presents  itself  between  the 
blades  of  the  instrument.  The  advantages  of  this  position  of  the 
forceps,  are,  1st.  That  the  head  is  seized  in  its  smallest  diameter; 
and  this  diameter  is  so  little  increased  by  the  thickness  of  the  in- 
strument, as  to  offer  no  additional  difficulty  to  the  delivery.  In- 
deed it  may  be  justly  doubted,  if  the  forceps  increase  the  diame- 
ter in  the  least,  as  their  thickness  is  lost  by  the  yielding  of  the 
head  of  the  child;  for  compression  to  a  certain  extent  must  al- 
ways be  made  during  the  operation  of  the  instruments,  and  the 
united  thickness  of  both  blades  does  not  exceed  four  or  five  lines. 
2d.  When  the  head  requires  to  be  compressed,  the  compression 
will  be  in  the  direction  of  the  short  diameter  of  the  head,  and  will 
oblige  the  vertex  to  extend  itself,  (however  little,)  in  the  direc- 
tion of  the  oblique  diameter;  as  its  construction  gives  a  tendency 
to  that  direction. 

785.  The  proper  application  of  the  forceps  farther  consists  in 
such  a  direction  of  its  blades,  as  will  permit  their  concave  edges 

*  Dr.  Davis,  (Elem.  Oper.  Mid.)  thinks  the  bi'cadth  of  the  French  forceps 
is  too  narrow  and  proposes  those  of  much  gi-eater  breadth.  I  have  never  found 
any  inconvenience  in  the  use  of  these  instruments,  which  was  exclusively  charge- 
able to  thia  circumstance. 


292  OF  COMPRESSION. 

to  come  under  the  arch  of  the  pubes,  at  the  last  period  of  labour 
— this  rule  is  never  to  be  violated.  They  must  be  placed  exactly 
parallel  upon  the  sides  of  the  head,  that  they  may  lock;  and  it  is 
ascertained  that  they  are  well  placed,  by  their  locking  w^ithout 
the  necessity  of  force.  Should  they  not  lock  spontaneously,  if  we 
may  use  the  expression,  force  must  not  be  used  to  make  them — 
for  if  it  be  employed  for  this  purpose,  it  must  necessarily  be  at  the 
expense  of  the  bones  of  the  head,  and,  perhaps,  the  destruction 
of  the  child.  If  the  handles  do  not  readily  join  upon  the  intro- 
duction of  the  second  blade,  we  may  be  certain  one  of  them  has 
a  wrong  direction;  it  must  be  ascertained  which,  and,  by  a  judi- 
cious management  of  the  one  in  fault,  make  it  join,  without  force, 
its  fellow.* 

786.  When  the  handles  join  kindly,  we  may  be  certain  the 
blades  are  properly  applied;  and  one  of  the  greatest  difficulties 
of  the  forceps  is  overcome.!  The  degree  of  compression  to  be 
applied  must  be  determined  by  the  size  of  the  child's  head;  its 
suppleness;  and  the  capacity  of  the  pelvis — the  less  compression 
the  head  requires,  the  easier,  and  the  more  successful  will  be  the 
operation. 

787.  The  forceps  have  two  modes  of  action;  a.  That  of  com- 
pression, in  the  first  instance;  h.  and  that  of  traction  and  com- 
pression, in  the  second. 

a. —  Of  Compression. 

788.  I  have  already  stated,  that  when  the  forceps  are  well  ap- 
plied, they  traverse  the  head  in  the  direction  of  its  oblique  dia- 
meter, or  nearly  so;  and  that  the  compression  which  it  may  suf- 
fer, is  in  the  direction  of  its  small  diameter;  now,  as  we  cannot 
determine  a.  priori,  the  size  of  the  head;  the  firmness  of  its  bones; 
nor  the  resistance  it  will  meet  with  in  its  passage,  we  cannot 
possibly  calculate  the  force  that  will  be  necessary  to  reduce  the 
head  sufficiently  to  permit  it  to  pass  through  the  pelvis.  I  can, 
therefore  only  say,  the  less  force  it  is  necessary  to  exert,  the  less 

*  Nothing  more  clearly  points  out  the  importance  of  an  entire  knowledge  of 
the  mechanism  of  labour;  and  the  gi-eat  necessity  of  learning  to  detect  the  ex- 
act position  of  the  head  within  the  pelvis  by  means  of  the  sutures,  than  the  diffi- 
culty an  ignorant  practitioner  always  finds  in  ascertaining,  wliich  of  the  blades 
of  the  forceps  is  in  fault  when  they  do  not  lock. 

f  We  may  make  one  exception,  however  to  this;  namely,  when  the  head  is 
high  in  the  pelvis,  and  the  extremities  of  the  forceps  have  only  been  applied 
upon  a  small  portion  of  it;  in  this  case  the  head  is  not  embraced  by  these  in- 
struments; it  is  only  partially  included,  and  they  will  consequently  slip. 


OF  COMPKESSION.  293 

the  head  will  suffer;  and  consequently,  so  far  as  this  operation  is 
directly  concerned,  the  greater  the  chance  will  be  of  preserving 
the  life  of  the  child — and  also,  that  the  converse  of  this  is  equally 
true.  Inattention  to  this  latter  fact,  or  a  want  of  knowledge  of  it, 
has  given  rise  to  many  of  the  objections  which  are  urged  against 
the  forceps — for  it  has  occasioned  their  application  upon  any  por- 
tion of  the  head ;  and  the  handles  forced  to  lock,  at  the  expense 
of  the  fracture  of  the  skull;*  it  has  occasioned  them  to  be  employ- 
ed, where  there  was  so  much  disparity  between  the  diameters  of 
the  head  of  the  child  and  the  pelvis,  that  it  could  only  be  deliver- 
ed, after  the  forceps  had  nearly  broken  down  its  texture;  need  I 
say  what  mischief  would  follow  such  displays  of  ignorance?  the 
child  dies  by  a  species  of  murder;  and  the  mother,  especially,  in 
the  latter  instance,  is  subjected  to  inflammation,  gangrene,  slough- 
ing, or  even  death. 

789.  It  has  been  imagined,  from  the  elongation  which  the  head 
sometimes  permits  in  long-protracted  labours,  that  it  would  bear 
with  impunity  any  compressing  force,  which  might  be  applied; 
but  this  is  an  error;  and  an  error  of  great  magnitude;  for  by  act- 
ing upon  it,  the  benefits  of  the  forceps  have  not  only  been  under- 
valued, but  really  called  in  question.  I  must  then,  to  prevent  the 
perpetuation  of  this  mistake,  as  far  as  may  be  in  my  power,  de- 
clare, that  the  head  will  bear  with  safety  but  a  moderate  diminu- 
tion of  its  bulk,  by  the  compressing  force  of  the  forceps;  and  of- 
tentimes, much  less  than  is  sometimes  observed  to  take  place, 
when  the  child  has  been  delivered  solely  by  the  exertion  of  the 
natural  powers;  the  reason  of  this  is  obvious;  we  cannot,  by  any 
contrivance  of  art,  imitate  this  gradual,  (though  not  always  safe,) 
modification  of  the  head;  consequently,  when  it  becomes  reduced 

*  I  was  once  called  upon  to  determine  whether  any  thing-  could  be  done  for 
a  newly-born  child,  which  had  been  most  unskilfaUy  delivered  by  the  forceps. 
— The  frontal  bone  was  severely  indented  by  the  edge  of  the  forceps;  and  one 
eye  entirely  destroyed,  by  the  extremity  of  the  blade  having  been  fixed  upon  it: 
yet  it  was  born  ahve.  The  case  was  of  coui'se  a  helpless  one;  and  the  child 
fortunately  died,  in  a  few  hours  after  its  birth.  I  was  once  shown  a  blade  of 
the  forceps,  which  had  been  excessively  bent,  by  an  endeavour  to  make  it  lock. 
In  this  case,  the  forceps  were  exhibited  in  triumph,  as  a  proof  of  tlie  great  diffi- 
culty  the  operator  had  to  encounter,  in  effecting  the  delivery;  and  as  additional 
evidence  of  this,  he  declared,  that  no  strength  was  sufficient  to  deliver  the  head, 
as  both  his,  (and  he  was  a  powerful  man,)  and  that  of  an  equally  ignorant  prac- 
titioner, were  unavailingly  exerted,  alternately  and  collectively — he  at  last  de- 
livered with  the  crotchet,  after  having  experienced  very  great  difficulty  in 
withdrawing  the  bent  blade  of  the  forceps. 


294  MODE  OF  ACTING  AFTER  APPLICATION. 

by  a  suddenly  applied  force,  like  that  exerted  by  the  forceps,  it 
must  be  at  the  hazard  of  doing  much  injury,  or  it  may  be  even 
fatal  to  the  child.* 

790.  This  fact  limits  the  powers  of  the  forceps  more  than  is 
commonly  supposed,  even  by  those  who  employ  them  with  the 
laudable  hope  of  saving  the  lives  of  both  mother  and  child;  but 
who  frequently  experience  disappointment,  because  not  aware  of 
it.  The  forceps,  therefore,  in  the  hands  of  those  who  consider 
them  as  a  means  by  which  a  difficult  labour  may  be  terminated, 
but  who  apply  them  without  rule,  or  without  a  knowledge  of 
their  mode  of  action,  are  nearly  as  fatal  as  the  crotchet  itself;  be- 
cause they  are  regardless  of  the  degree  of  compression  they  im- 
pose upon  the  head  during  its  extraction.!  It  would  seem,  then 
from  all  experience  to  follow,  that  from  a  pelvis  with  less  than 
three  inches,  or  even  three  inches  and  a  half  in  its  small  diame- 
ter, a  child's  head  at  full  time  cannot  be  made  to  pass  with  safety, 
by  means  of  the  forceps,  unless  there  be  an  unusual  degree  of 
suppleness  in  the  bones  of  the  cranium;  or  the  head  itself  unu- 
sually sniall.  If  these  facts  were  more  generally  know-n,  or  more 
constantly  kept  in  view,  we  should  have  fewer  complaints  against 
the  forceps,  because  there  would  be  fewer  victims  to  their  ill-di- 
rected power  upon  the  head  of  the  child,  and  fewer  evils  follow- 
ing their  application  upon  the  soft  parts  of  the  mother. 

b.  —  Compression  and  Traction. 

791.  It  is  in  but  very  few  cases  that  we  can  avoid  a  pretty 
constant  compression,  from  the  moment  of  their  application  upon 
the  head  of  the  child  until  its  final  delivery.  With  a  view  to 
diminish  the  permanency  of  this  pressure  as  much  as  possible,  I 
am  in  the  habit  of  not  tying  the  extremities  of  the  handles,  as  is 
usually  recommended,  that  I  may  after  each  tractive  effort,  per- 
mit the  instruments  to  expand,  as  much  as  the  elasticity  of  the 

•  Dr.  Davis,  however  asks,  "whether  in  some  particular  circumstances  It 
might  not  be  found  more  ehg-ible  to  apply  to  the  foetal  head  a  certain  required 
amount  of  compressing  force,  within  a  short  time,  artificially  by  means  of  the 
forceps  than  to  await  the  result  of  a  more  gradual  and  proti-acted  application 
of  an  ultimately  equal  degree  offeree  by  tlie  natm-al  agents  of  pai-turition  ?" — 
{Elem.  Oper.  Mid.  p.  139.) 

f  I  have  more  than  once  witnessed  the  truth  advanced  here.  I  have  seen 
the  whole  length  or  nearly  the  whole  length  of  the  frontal  bone  cut  through, 
by  one  of  the  sharp  edges  of  the  forceps,  by  an  effort  to  compress  it;  and  at 
another,  I  have  seen  the  parietal  bone  in  the  same  wretched  plight,  from  the 
same  cause. 


MODE  OP  ACTING  AFTER  APPLICATION.  295 

head,  and  the  restricted  capacity  of  the  pelvis  will  permit.  In 
this,  I  think  there  is  decidedly  an  advantage  to  the  child;  and  no 
possible  injury  can  happen  from  it,  to  the  mother. 

d. — Mode  of  Acting  after  A  implication. 

792.  Each  effort  made  to  advance  the  head  after  the  forceps 
have  been  applied,  must  be  considered  as  a  renewed  compression, 
though  the  lateral  pressure  may  be  but  very  little  increased;  for 
in  order  that  the  head  may  advance,  the  curved  extremities  of 
the  instruments  must  necessarily  act  at  nearly  right  angles  with 
their  sides;  consequently,  the  transverse  diameter  must  be  a  little 
increased,  or  rather  not  so  much  diminished,  as  if  the  pressure 
were  strictly  and  only  lateral ;  this  consequently  must,  to  a  cer- 
tain extent,  increase  the  difficulty  of  delivery;  or  in  other  words, 
increase  the  necessity  of  a  stronger  tractive  force.  This,  how- 
ever, is  in  some  measure,  if  not  altogether  obviated,  by  making 
each  blade  of  the  forceps  act  alternately  as  a  lever  in  conducting 
the  delivery;  and  this  is  the  usual  direction  given  for  their  em- 
ployment, without  expressing  the  reason  for  it — hence,  when 
the  instruments  are  fixed,  we  act  with  much  greater  effect,  by 
drawing  from  blade  to  blade,  than  if  we  continued  the  force  in  a 
direct  line;  for  by  making  the  handles  describe  a  portion  of  a 
circle,  by  passing  them  from  right  to  left,  and  the  reverse,  dur- 
ing the  traction,  we  each  time,  (when  the  head  is  movable,) 
make  a  part  of  its  side  sink  lower  into  the  pelvis,  and  advance  to- 
wards the  external  opening  of  the  pelvis. 

793.  The  extent  of  this  motion  of  the  handles  must,  at  first 
be  very  small,  especially  if  the  head  be  high  in  the  pelvis;  or 
we  shall  be  making  fulcra  of  the  soft  and  bony  parts  of  the  mo- 
ther at  each  effort,  which  must  always  be  carefully  avoided.  As 
the  head  advances,  we  may  enlarge  the  space  through  which  the 
handles  are  to  move,  but  it  is  never  to  be  so  extensive  as  to  make 
the  instruments  press  with  much  force  against  the  bones,  form- 
ing the  arch  of  the  pubes,  and  the  external  soft  parts  of  the  mo- 
ther. 

794.  The  motion  just  spoken  of,  is  at  first  horizontal,  or  very 
nearly  so;  but  as  the  head  advances,  we  are  obliged  to  elevate 
the  extremities  of  the  instruments,  and  this  in  proportion,  as  it 
approaches  the  vulva,  or  as  it  is  about  to  escape  the  external 
machinery;  so  that  at  the  last  moments,  the  extremities  of  the 
handles  are  laid  nearly  upon  the  abdomen  of  the  mother.  Dur- 
ing the  operation,  our  tractive  efforts  should  coincide  with  the 


296  RECAPITULATION. 

action  of  the  uterus,  whenever  that  remains;  when  the  uterus 
has  ceased  to  act,  we  should  permit  as  much  time  to  elapse  be- 
tween each  exertion,  as  generally  takes  place  between  the  pains 
at  this  period  of  labour,  that  we  may  not  exhaust  the  woman; 
that  we  may  secure  the  tonic  contraction  of  the  uterus,  and  that 
we  may  not  make  too  suddenand  too  long  continued  compres- 
sion on  the  child's  head. 

795.  It  is  by  no  me^ins  unusual  for  the  pains  to  cease  after  the 
application  of  the  forceps;  and  we  are  obliged,  in  consequence, 
to  perform  the  delivery  without  their  aid — I  am  at  a  loss  to  ac- 
count for  this;  for  it  is  contrary  to  what  might  reasonably  be 
expected.  When,  however,  they  continue  with  even  moderate 
force,  I  have  been  in  the  habit  of  disengaging  the  instruments, 
when  the  head  is  about  to  pass  through  the  external  parts,  that 
these  may  be  the  better  supported,  and  the  risk  of  laceration  di- 
minished. Should  there  be  no  pain,  we  are  then  constrained  to 
continue  our  efforts,  until  the  head  is  without. 

796.  In  removing  the  forceps  before  the  head  is  delivered,  I 
am  aware  I  am  departing  from  high  authority;  for  Dr.  Denman 
lays  it  down  as  a  rule  that  "  in  every  case  in  which  the  forceps 
have  been  applied,  they  are  not  to  be  removed  before  the  head 
is  extracted,  even  though  we  might  have  little  or  no  occasion  for 
them."  But  notwithstanding  this  positive  injunction,  I  am  en- 
tirely persuaded,  from  experience,  it  is  the  safer  practice,  if  we 
regard  the  integrity  of  the  soft  parts  of  the  mother,  worth  pre- 
serving. 

Sect.  II. — Recapitulation. 

797.  As  I  have  dwelt  upon  the  use  of  the  forceps  longer  than  I 
had  intended,  I  shall  sum  up  in  a  few  words  the  principal 
points  intended  to  be  insisted  on,  or  illustrated:  1st.  That  the 
long  French  forceps  are  preferable  to  the  English  short  forceps, 
even  for  the  unskilful;  2d.  The  best  position  for  the  woman  is 
that  recommended  for  turning;  3d.  The  bladder  and  rectum  are 
to  be  emptied  before  the  forceps  are  introduced ;  the  former  by 
the  catheter,  when  the  woman  cannot  command  the  discharge; 
and  the  latter  by  an  injection,  if  it  has  not  been  done  Sj^onta- 
neously,  a  short  time  before;  4th.  The  patient  and  friends  are 
always  to  be  apprized  of  the  necessity  and  propriety  of  the  ope- 
ration before  it  is  resorted  to;  5th.  The  vagina,  external  parts, 
and  the  instruments,  are  to  be  coated,  by  fresh  hog's  lard,  or  soft 
pomatum    and  the  instruments  always  warmed  ;  6th.  The  for- 


RECAPITULATION.  297 

ceps  are  never  to  be  employed  before  the  os  uteri  and  external 
parts  are  relaxed;  and  the  membranes  ruptured;  7th.  This  relax- 
ation to  be  promoted  by  ihe  best  adapted  means ;  Sth.  Should  the 
uterus  be  in  a  proper  condition  for  the  operation,  and  the  mem- 
branes at  the  same  time  entire,  the  latter  must  be  ruptured,  that 
the  application  of  the  forceps  need  not  be  delayed,  when  the  case 
requires  immediate  interference ;  9th.  When  the  circumstances  of 
the  case  require  the  use  of  these  instruments,  the  application 
should  not  be  too  long  delayed,  from  an  imaginary  fear,  that  the 
woman  might  suffer  from  their  use,  or  from  an  ill-grounded  hope 
that  the  woman  may  deliver  herself — we  should,  therefore,  not 
permit  her  to  be  exhausted,  or  the  child  to  perish,  because  feeble 
or  inefficient  pains  attend,  or  because  the  head  of  the  child  has 
not  been  six  hours  in  the  passage;  10th.  The  blades  of  the  for- 
ceps are  always  to  be  applied  to  the  sides  of  the  head — that  is, 
over  the  ears  of  the  child — when  necessity,  (Avhich  is  very  rare,) 
obliges  us  to  depart  from  this  rule,  it  is  but  an  exception  to  the 
rule;  11th.  They  must  be  applied  so  that  their  upper,  or  concave 
edges,  will  come  under  the  arch  of  the  pubes,  at  the  last  period 
of  labour;  12th.  Should  the  handles  of  the  instruments  not  join 
with  ease,  we  may  be  certain  they  are  ill-applied;  the  cause  of 
their  not  locking  must  be  ascertained;  and  they  are  never  to  be 
joined  by  force;  13th.  The  head  will  not  permit  with  safety,  but 
a  moderate  approximation  of  its  sides;  therefore,  when  compres- 
sion is  carried  beyond  this  point,  the  destruction  of  the  child  is 
sure:  14th.  With  a  view  to  prevent  all  unnecessary,  and  too  long 
continued  pressure  upon  the  head  of  the  child,  the  handles  of  the 
forceps  should  not  be  tied;  but  after  each  tractive  effort,  they 
must  be  permitted  to  expand  themselves,  by  ceasing  to  press  upon 
them;  15th.  Each  traction  should  be  made  from  blade  to  blade; 
that  each  may  act  as  a  lever  upon  the  head;  16th.  The  extent 
of  the  motion  of  the  handles  for  this  last  purpose,  must  be  regula- 
ted by  the  distance  the  head  is  from  the  external  parts;  for  the 
less  the  head  is  advanced,  the  more  circumscribed  should  be  the 
motion ;  and  the  reverse — this  motion  is  at  first  nearly  horizontal;* 
17th.  The  external  extremities  of  the  instruments  must  be  raised 
towards  the  abdomen  of  the  mother,  in  proportion  as  the  head  ad- 
vances through  the  external  parts;  ISth.  Should  pains  continue 
until  the  head  has  nearly  passed  through  the  external  parts,  the 

*  That  la,  irom  one  thigh  of  tlie  mother  to  the  otlier. 
38 


29S  GENERAL  OKSERVATIOXS  UPON  THE  FORCEPS. 

forceps  may  be  removed;  but  if  none  attend,  the  delivery  must 
be  completed  by  the  forceps. 

Sect.  III. — General  Observations  upon  the  Forceps. 

798.  In  delivering  by  means  of  the  forceps,  every  attention 
should  be  paid  to  delicacy,  and  every  care  should  be  taken  that 
the  patient  be  not  subjected  to  unnecessary  pain;  to  fulfil  the  first, 
the  patient  should  not  be  exposed;  this  cannot  be  necessary,  even 
for  the  drawing  off  of  the  urine,  should  that  be  an  essential  pre- 
vious step.  The  operator  must  become  familiar  with  the  intro- 
duction of  the  instruments  without  the  aid  of  sight,  more  especi- 
ally as  this  cannot  serve  hbn,  and  must,  if  employed,  be  highly 
offensive  to  the  patient.  He  must  perform  his  duty  under  cover; 
and  the  guide  for  his  instrument  must  be  the  hand  in  which  the 
instrument  is  not  held — this,  of  course,  will  sometimes  be  the  right, 
and  at  others  the  left — two  or  three  fingers  must  be  introduced 
so  as  to  touch  the  child's  head  when  at  the  lower  strait,  and  the 
extremities  of  them  must  be  insinuated  under  the  edge  of  the  os 
uteri  if  that  is  still  down;  and  upon  the  plane  thus  formed  by  the 
fingers,  the  instruments  must  be  conducted;  with  this  precaution 
he  shall  give  no  unnecessary  pain;  since  it  will  prevent  the  edge 
of  the  uterus  from  being  included  between  the  blade  of  the  for- 
ceps and  the  head  of  the  child. 

799.  Should  the  head  of  the  child  have  escaped  from  the  os 
uteri,  he  must  pass  the  instruments  in  such  a  manner  as  shall  con- 
duct their  extremities  under  its  edges ;  this  is  done  by  keeping  the 
point  of  the  blade  pretty  firmly  passed  against  the  scalp  of  the 
child  as  it  passes  into  the  pelvis — should  it,  however,  meet  with 
any  obstruction  in  its  passage,  the  difficulty  must  be  overcome  by 
address,  and  not  by  force — it  may  be  a  fold  of  the  scalp,  or  it  may 
be  the  ear,  by  which  the  point  of  the  instrument  is  arrested  ;  gen- 
tly depressing  the  handle  of  the  instrument,  or  varying  its  direc- 
tion a  little,  will  almost  always  surmount  this  difficulty. 

800.  Should  much  pain  be  experienced  by  an  attempt  to  lock 
the  blades  when  well  applied,  as  regards  their  position,  we  may 
be  pretty  certain,  a  portion  of  the  neck  of  the  uterus  is  included 
in  the  grasp  of  the  instruments — we  must  inquire  on  which  side 
of  the  pelvis  the-pain  is  felt,  and  withdraw  the  blade  from  it,  and 
introduce  it  anew.  Should  cramps  be  induced,  we  may  some- 
times relieve  them  by  elevating  or  depressing  the  handles  of  ^le 
forceps. 


GENERAL  OBSERVATIONS  UPON  THE  FORCEPS,  299 

801.  The  greatest  care  must  be  taken  before  we  begin  our 
traction,  that  no  portion  of  the  mother  is  included  in  the  locking 
of  the  blades — this  must  be  done  by  passing  a  finger  entirely- 
round  the  place  of  union.  This  accident  very  rarely  occurs  in  the 
use  of  the  long  forceps,  unless  the  head  is  high  in  the  pelvis — with 
the  short  it  is  frequent,  even  under  the  direction  of  the  most  care- 
ful operator;  this  forms,  in  my  estimation,  a  very  serious  objection 
to  their  employment.  I  was  once  called  to  a  poor  woman  who 
had  had  a  considerable  portion  of  the  internal  face  of  the  right 
labium  removed,  by  having  been  included  in  the  joint  of  the  short 
forceps. 

802.  When  the  instruments  are  properly  adjusted,  we  should 
seize  the  hooked  extremities  with  the  right  hand,  and  make  them 
approach  each  other  in  the  most  gradual  manner;  and  make  no 
more  compression  than  is  absolutely  necessary  to  secure  a  certain 
hold,  or  to  enable  the  head  to  pass:*  The  left  hand  must  be  applied 
over  the  joint  of  the  instruments,  and  in  a  manner  that  will  per- 
mit the  point  of  the  index  finger  to  touch  the  head  of  the  child, 
which  will  enable  him  to  determine  the  progress  it  makes.  We 
commence  the  traction  with  a  very  small  force,  and  gradually 
augment  it  to  the  extent  we  may  judge  necessary — we  should 
finish  the  effort  by  gradually  diminishing  the  force,  until  it  comes 
to  a  state  of  rest;  taking  care,  however,  to  maintain  the  advan- 
tage we  have  gained,  by  removing  the  pressure  from  the  handles, 
and  hooking  two  fingers  in  their  curved  extremities,  and  thus  pre- 
vent the  receding  of  the  head.  When  we  have  indulged  the  ute- 
rus in  a  sufficient  interval,  or  upon  the  accession  of  a  pain,  we  are 
to  apply  our  hands  as  just  directed,  and  act  as  before. 

803.  As  the  head  is  about  to  pass  through  the  external  parts, 
the  left  hand  must  forsake  the  instruments,  and  apply  itself  firmly 
against  the  now  distended  perinaeum;  and  if  there  be  sufficient 
power  in  the  uterus  to  carry  the  head  through  the  os  externum, 
without  farther  aid  of  the  forceps,  they  should  be  removed,  as  ad- 
vised; but  if  not,  they  must  be  suflered  to  finish  the  delivery. 

804.  When  the  head  is  without,  the  same  care  should  be  ex- 
ercised as  was  recommeiKled  in  a  natural  labour;  that  is,  not  to 

*  When  the  pelvis  is  deformed,  and  tlie  relation  between  it  and  tlie  head  of 
the  child  is  very  strict,  we  are  obliged  to  depart  from  this  rule,  and  apply  a 
much  stronger  compressing  force;  as  the  diameter  of  the  head  must  be  a  little 
diminislied,  that  it  may  pass — in  this  instance,  the  handles  are  to  be  brought  to- 
gether, and  secured  by  a  garter  or  ribbon. 


300  OF  THE  SPECIFIC  APPLICATION  OP  THE  FORCEPS. 

hurry  the  shoulders  through  the  pelvis;  that  the  tonic  contraction, 
may  certainly  follow  their  expulsion. 

805.  It  is  frequently  more  convenient  to  stand  to  perform  this 
operation  than  to  sit;  but  a  chair  should  be  at  hand,  that  we  may 
use  it  after  the  head  is  delivered:  we  should  order  a  sheet  suffi- 
ciently folded,  to  be  spread  over  our  lap,  that  we  may  receive  the 
child  upon  it,  when  the  body  is  expelled.  The  funis  must  be  cut 
at  a  proper  time,  and  the  rest  of  the  delivery  finished  as  on  ordi- 
nary occasions. 


CHAPTER  XXI. 

OF  THE  SPECIFIC  APPLICATION  OF  THE  FORCEPS. 

806.  Generally  speaking,  the  difficulty  of  applying  these  in- 
struments is  in  proportion  to  the  remoteness  of  the  head  from  the 
inferior  strait,  and  the  facility  of  application,  as  the  vertex,  or 
forehead,  may  be  near  the  arch  of  the  pubes.  It  would  be  well, 
were  it  always  practicable,  or  a  subject  of  choice,  that  the  young 
practitioner  should  commence  with  the  most  simple  cases,  and 
gradually  advance  to  the  more  difficult  positions  of  the  head — but 
as  this  is  impossible  under  the  circumstance  of  ordinary  practice, 
he  should,  while  in  his  power,  become  in  some  measure  familiar 
with  the  application  of  the  forceps,  by  diligently  practising  upon 
the  machine — indeed  it  would  be  highly  advantageous  to  all  who 
may  be  about  to  engage  in  obstetrical  practice,  to  order  a  machine 
as  an  appendage  to  their  instruments.  By  the  use  of  this  contriv- 
ance he  can  become  well  acquainted  with  every  important  pre- 
sentation, and  at  the  same  time  render  himself  master  of  their  re- 
spective mechanisms;  he  can  familiarize  himself  to  the  application 
of  instruments,  and  readily  teach  himself  the  routine  of  turning,  &c. 

807.  I  shall  lay  down  the  rules  for  the  application  of  the  for- 
ceps in  every  presentation  as  succinctly  as  the  subject  will  permit, 
knowing  from  long  observation,  that  nothing  but  a  careful  expe- 
rience with  the  living  subject  can  ever  make  a  man  adroit  in  their 
use.  I  shall  therefore  commence  with  the  most  simple  cases,  and 
graduall}'  advance  to  the  more  complicated  and  difficult. 


OF  THE  SPECIFIC  APPLICATION  OF  THE  FORCEPS.  301 

808.  The  various  ways  which  the  head  of  the  child  lAay  offer 
to  the  pelvis,  when  it  may  he  necessary  to  terminate  the  labour 
by  the  forceps,  are, 

809.  a.  1st.  Where  the  vertex  answers  to  the  arch  of  the  pubes, 
and  the/orehcad  to  the  sacrum. 

810.  b.  2d.  The  reverse  of  this,  the  ybreAe«c^  to  the  pubes, 
and  vertex  to  the  sacrum. 

811.  c.  3d.  Where  the  ^-er^ear  is  behind  the  left  foramen  ovale, 
and  ihe  forehead  to  the  right  sacro-iliae  symphysis. 

812.  d.  4th.  Where  the  forehead  is  behind  the  left  foramen 
ovale,  and  the  vertex  to  the  right  sacro-iliac  symphysis. 

813.  e.  5th.  Where  the  vertex  is  behind  the  right  foramen 
ovale,  and  \he  forehead  to  the  left  sacro-iliac  symphysis. 

814.  f.  6th.  Where  ihe  forehead  is  behind  the  right  foramen 
ovale,  and  the  vertex  to  the  left  sacro-iliac  symphysis. 

815.  g.  7th.  Where  the  position  of  the  head  is  directly  trans- 
versal: 1st.  Wliere  the  vertex  answers  to  the  left  side  of  the 
pelvis;  and  2d.  Where  it  answers  to  the  right. 

Sect.  I. — a.  1st.  Jipplication  of  the  Forceps  in  the  First  of 
these  Positions. 

816.  The  woman  about  to  be  delivered  with  the  forceps  is  con- 
stantly supposed  to  be  placed  upon  her  back,  and  every  other  cir- 
cumstance, arranged  as  already  directed. 

817.  The  first  position  in  which  we  are  to  apply  the  forceps. 
Dr.  Denman  thinks  can  very  rarely  require  them — this  by  no 
means  comports  with  my  experience;  for  I  have  very  often  been 
under  the  necessity  of  using  them  in  this  situation  of  the  child's 
head;  for  any  one  of  the  causes  which  I  have  considered  capable 
of  complicating  a  labour,  may  happen  at  this  period,  as  well  as 
any  other.  What  is  there  in  this  position  which  shall  protect 
the  woman  against  flooding,  convulsions,  exhaustion,  &c.  and  ren- 
der immediate  interference  unnecessary.''  I  can  see  nothing; 
for,  though  the  labour  is  near  its  completion,  it  is  not  completed; 
and  I  am  convinced,  that  in  many  cases  both  mother  and  child 
have  suffered  from  the  delay  which  Dr.  Denman's  repugnance  to 
the  employment  of  these  instruments  has  created  with  the  prac- 
titioners, who  consider  him  the  best  authority.  W^ere  it  neces- 
sary it  would  be  easy  to  give  examples  to  prove  what  I  have  just 
said.     (See  765,  771,  772.) 


302  OP  THE  SPECIFIC  APPLICATION  OP  THE  FORCEPS. 

818.  In  this  case,  after  duly  preparing  the  forceps  as  ah'eady 
directed,  we  take  hold  of  the  male  branch  of  the  forceps  with  the 
left  hand,  and  hold  it  as  we  would  a  pen  when  writing,  while  we 
introduce  two  or  three  fingers  of  the  right  hand  into  the  vagina 
against  the  child's  head,  and  under  the  edge  of  the  uterus  if  prac- 
ticable ;  we  then  hold  the  handle  or  blade  nearly  perpendicular, 
but  inclining  to  the  right  side  of  the  mother,  and  insinuate  the 
extremity  of  the  blade  between  the  labia,  and  slide  it  along  the 
fingers  intended  as  a  guide,  until  it  reaches  four  or  five  inches 
within  the  pelvis;  gradually  depressing  the  handle  as  it  advances, 
and  as  it  embraces  the  head.  It  rarely  happens  that  any  diffi- 
culty is  experienced  in  the  introduction  of  this  blade;  its  position, 
if  properly  applied,  is  strictly  lateral ;  its  concave  edge  being  un- 
der the  arch  of  the  pubes,  the  pivot  will  have  a  vertical  position, 
while  the  handle  will  be  sustained  by  the  edge  of  the  perinseum. 
The  instrument  must  be  retained  in  this  position  either  by  an  as- 
sistant, or  by  placing  it  on  the  knee,  while  you  prepare  for  the  in- 
troduction of  the  other  blade — this  must  be  taken  in  the  right 
hand,  as  directed  for  the  other  blade  ;  and  must,  like  it,  be  con- 
ducted to  its  proper  situation  by  two  or  three  fingers  of  the  left 
hand;  when  advanced  as  far  within  the  pelvis  as  the  first  blade, 
the  handle  must  be  lowered  and  inclined  towards  the  left  thigh  of 
the  mother,  until  it  crosses  the  first  blade,  and  locks  with  it — if 
the  instruments  are  properly  applied,  this  will  readily  happen — 
the  pivot  will  be  vertical,  and  must  be  turned,  that  the  blades  may 
be  secured  in  their  position  with  each  other — the  handles  are  now 
to  be  seized,  and  the  delivery  conducted  as  already  directed. 

Sect.  II. — b.  2d.  Jipjolication  in  the  Second  of  these  Positions. 

819.  This  position,  (810)  is  by  no  means  as  favourable  for  de- 
livery as  the  first,  though  not  more  difficult  for  the  use  of  the  for- 
ceps; the  presence  of  the  forehead  under  the  pubes,  as  I  have  al- 
ready stated,  (633)  always  renders  it  more  diflicult  for  the  woman 
to  deliver  herself;  and  sometimes  is  of  itself  a  sufficient  reason 
for  the  use  of  the  forceps.*     The  application  of  the  forceps,  is, 

*  Mrs.  S.,  May  7tli,  1827,  in  !al)our  with  her  second  child;  the  presentation 
was  the  fifth,  but  could  not  be  reduced  to  the  first  by  any  effort  I  could  make, 
owing  to  the  large  size  of  the  child's^head.  After  waiting  unavailingly  for  sev- 
eral hours  for  the  natural  powers  to  effect  the  delivery,  I  was  obliged  to  use  the 
forceps.  I  have  no  doubt  but  the  use  of  instruments  would  have  been  unneces- 
sary in  this  case,  had  the  vertex  have  presented,  as  the  pelvis  was  ample  as  or- 


OF  THE  SPECIFIC  AFPLICATION  OF  THE  TORCEPS.  303 

however,  precisely  the  same  as  in  the  one  just  described;  we  are 
only  to  observe,  in  finishing  the  labour,  to  permit  the  vertex  to 
turn  backward,  as  it  is  described  to  do  when  speaking  of  its  me- 
chanism. 

Sect.  III. — c.  3d.  Application  of  the  Forceps  in  the  third  of 
these  Positions. 

820.  The  application  of  the  forceps  in  this  situation  (Sll)  of 
the  head  is  more  difficult  than  in  the  two  preceding;  owing  to 
the  oblique  manner  in  which  it  offers  at  the  lower  strait.  It 
must  assume  this  position  before  it  can  offer  its  vertex  to  the 
opening  of  the  pelvis,  but  it  may  fail  to  make  this  necessary  change, 
and  thus  render  the  labour  difficult;  or  the  causes  which  may 
complicate  any  labour  may  operate  at  the  moment  the  head  has 
arrived  at  the  place  designated,  and  thus  render  the  use  of  the 
forceps  indispensablei 

821.  When  the  forceps  are  to  be  used,  the  male  blade  must  be 
passed  to  the  left  side  of  the  pelvis  at  about  the  same  distance  as 
before  directed;  it  will  almost  always  pass  along  easily,  after  hav- 
ing spontaneously  assumed  a  change  of  position;  this  change  car- 
ries the  handle  a  little  toward  the  left  thigh  of  the  mother,  and 
gives  to  the  pivot  an  oblique  position,  instead  of  the  vertical  one 
before  spoken  of — after  the  first  blade  is  adjusted,  the  other  must 
be  passed  nearly  opposite  to  it,  but  a  little  higher,  and  immedi- 
ately against  the  right  leg  of  the  pubes,  and  behind  the  right  for- 
amen ovale;  the  handle  must  be  made  to  incline  like  its  fellow  to 
the  left  thigh;  and,  if  properly  conducted,  the  blades  will  lock; 
but  in  a  manner  that  will  enable  the  pivot  to  preserve  its  look  to- 
wards the  left  groin  of  the  mother. 

822.  When  the  instruments  are  joined,  we  are  directed  by 
Baudelocque  and  others,  to  turn  the  vertex  towards  the  arch  of 
the  pubes;  but  this  is  certainly  not  always  necessary;  for  1  have 
usually  found,  that  this  took  place  spontaneously  as  I  continued 

dinary;  the  parts  well  relaxed;  and  the  pains"frequent  and  powerful.  As  this 
child  was  of  unusual  dimensions,  I  will  subjoin  tlie  measurement  of  several 
parts: 

16  6-8  inches  round  the  forehead  and  occiput. 
19  1-2    "         round  the  shoulders. 
5  5-8    "         round  tlie  arm  below  the  elbow. 
The  other  parts  of  the  body,  proportionably  large.     I'he  head  of  the  child 
was  lengthened  considerably;  but  it  recovered  its  shape  in  a  few  days. 


304  OF  THE  SPECIFIC  APPLICATION  OF  THE  FORCEPS. 

the  traction.  I  have  no  doubt  but  this  is  occasionally  necessary;* 
especially,  where  the  pelvis  is  rather  narrow,  or  the  head  large, 
and  when  we  find,  after  successive  efibrts,  the  head  does  not  fol- 
low the  proper  direction,  we  may  turn  the  vertex  towards  the 
pubes,  by  gradually  bringing  the  pivot  to  a  vertical  position — 
when  this  is  done,  this  case  is  precisely  like  the  first  of  these  po- 
sitions, and  the  labour  must  be  finished  like  it. 

823.  In  several  instances  of  this  position,  I  have  found  it  easier 
to  introduce  the  second  blade  from  below,  pressing  the  handle  of 
the  first  blade,  pretty  firmly  against  the  perinaeum — that  is,  in- 
stead of  having  the  handle  high  over  the  abdomen,  to  place  it  un- 
der the  left  thigh  of  the  mother,  and  make  the  extremity  of  the 
blade  penetrate  from  downward,  upward;  care  must  be  taken  not 
to  place  the  female  blade  below  the  male,  in  this  case. 

Sect.  IV. — d.  4th.  Apjjlications  of  the  Forcejjs  in  the  fourth 
of  these  Positions. 

824.  This  position  (812)  unites  the  difficulty  of  the  oblique 
situation  mentioned  just  now,  with  the  disadvantage  of  the  fore- 
head under  the  arch  of  the  pubes;  and,  though  the  application 
of  the  forceps  is  precisely  the  same  as  in  the  last  described  posi- 
tion, it  will  nevertheless  be  a  more  difficult  operation,  for  the  rea- 
son just  stated.  At  the  last  period,  when  the  head  is  escaping, 
the  vertex  must  be  suffered  to  turn  backward,  as  in  the  second 
position. 

Sect.  V. — e.  5th.  JlpjjUcation  of  the  Forcej)s  in  the  fifth  of 
these  Positions. 

825.  This  position  (813)  is  of  more  difficult  management  than 
any  of  those  I  have  yet  described,  owing  to  the  necessity  of  plac- 
ing the  male  branch  above;  and  obliging  the  female  branch  to  be 
placed  below^ — but  these  difficulties  may  be  surmounted  by  gen- 
tleness and  perseverance,  and  by  a  just  knowledge  of  the  posi- 
tion of  the  head. 

*  Baudelocque  tells  us,  that  he  has  occasionally  failed  to  establish  the  vertex 
under  the  arch  of  the  pubes;  and,  in  these  cases,  the  head  has  passed  through 
the  inferior  strait  and  external  parts  in  a  diagonal  direction.  I  have  witnessed 
this  direction  of  the  head  in  a  number  of  instances,  where  the  forceps  were  not 
employed;  but  it  has  only  occurred  to  me  once,  when  employing  these  instru- 
ments— when  this  happens,  it  is  generally  owing  to  the  sacrum  beuig  too 
sti-aight. 


SPECIFIC  APPLICATION  OF  T^E  FORCEPS.  305 

826.  The  male  branch  of  the  forceps  must  be  conducted  by  the 
left  hand  behind  the  left  foramen  ovale;  this  must  be  done  by 
passing  the  extremity  of  the  blade  upon  two  or  three  fingers  im- 
mediately under  the  left  leg  of  the  pubes ;  the  handle  of  course 
must  be  depressed  in  proportion  to  the  advancement  of  the  blade, 
and  made  to  incline  towards  the  right  thigh  of  the  mother;  and, 
when  correctly  adjusted,  the  pivot  will  take  an  oblique  position, 
and  look  towards  the  right  groin  of  the  woman.  The  female 
blade  must  be  introduced  on  the  inferior  part  of  the  right  side  of 
the  pelvis,  and  adjusted  so  as  to  correspond  with  the  first  intro- 
duced blade — the  handles  must  then  be  locked,  and  seized  by  the 
left  hand  at  the  extremities  of  the  blades;  while  the  right  will 
take  hold  over  the  pivot;  a  finger  to  be  placed  against  the  head 
of  the  child,  as  before  directed. 

827.  It  is  not  generally  necessary  to  turn  the  vertex  towards 
the  pubes  in  this  case,  any  more  than  when  it  was  on  the  oppo- 
site side  of  the  pelvis;  this  will  take  place  as  in  the  former  case, 
by  observing  the  proper  direction,  for  the  tractive  forces. 

Sect.  VI.— /  6th.  Jipplication  of  the  Forceps  in  the  sixth  of 
these  Positions. 

828.  The  relations  of  the  head  and  pelvis  in  this  case,  (814)  as 
regards  diameters,  are  precisely  the  same  as  the  one  just  de- 
scribed; and  the  forceps  must  be  applied  in  the  same  manner. 
The  same  precaution  must  be  taken  at  the  final  passage  of  the 
head  through  the  external  parts,  to  permit  it  to  turn  backward. 

Sect.  VII. — g.  7th.  Jipplication  of  the  Forceps  in  the  seventh 
of  these  Positions. 

829.  Dr.  Denman,  inhis  Aphorisms,  seems  to  acknowledge  but 
one  mode  of  applying  the  forceps,  for  the  four  last  positions,  and 
the  one  now  under  consideration;  (815)  and  his  directions  for  all, 
are  only  applicable  to  the  last.  This  position  of  the  head  must 
be  rare;  at  least  I  have  encountered  it  but  once,  and  it  was  re- 
lieved by  one  blade  of  the  forceps  acting  upon  the  vertex,  so  as 
to  aid  the  efforts  of  the  uterus,  (which  were  very  strong,)  in 
bringing  it  towards  the  symphysis  pubis. 

830.  When  the  forceps  are  resolved  on,  and  the  vertex  of  the 
child  is  to  the  left  side  of  the  pelvis,  the  female  branch  of  the  for- 
ceps must  be  placed  behind  the  symphysis  pubis,   and  the  male 

39 


306      GENERAL  REMARf;S  ON  THE  USE  OF  THE  FORCEPS,  &C. 

blade  before  the  sacrum.  The  handles  of  the  instruments  should 
be  made  to  incline  towards  the  left  side  of  the  mother,  that  the 
vertex  may  descend  rather  more  than  the  forehead.  When  the 
vertex  is  on  the  opposite  side,  the  male  branch  must  be  inserted 
behind  the  pubes,  and  the  female  branch  before  the  sacrum;  the 
handles,  in  this  case,  must  be  inclined  to  the  right  thigh  of  the 
mother,  for  the  reason  just  stated. 


CHAPTER  XXII. 


GENERAL    REMARKS    ON   THE    USE    OF    THE    FORCEPS,    WHEN  THE 
HEAD  IS  ABOVE  THE  SUPERIOR  STRAIT. 

831.  Smellie  appears  to  be  the  first  who  had  either  sufficient 
skill  or  hardihood,  to  apply  the  forceps  when  the  head  was  free 
above  the  superior  strait,  and  since  his  time  he  has  had  but  few 
followers.*  This,  however,  has  not  arisen  so  much  from  the  con- 
templation of  its  dangers,  as  the  consciousness  of  its  difficulties. 
To  employ  the  forceps  with  success  under  such  circumstances,  it 
is  necessary  that  the  operator  be  aware  of  all  he  may  have  to  en- 
counter; as  well  as  be  skilled  in  their  application,  in  the  situa- 
tions we  have  just  considered ;  therefore  it  cannot  be  recommend- 
ed as  a  resource  to  inexperienced  practitioners. 

832.  Baudelocque's  observations  upon  this  subject  are  so  just 
and  so  important,  that  I  must  recommend  them  to  the  serious 
consideration  of  every  gentleman  who  may  intend  to  pursue  the 
practice  of  midwifery.  Fortunately,  the  necessity  of  operating 
with  the  forceps,  while  the  head  is  in  this  situation,  seldom  occurs; 
especially,  in  this  country,  where  almost  the  only  apology  for  their 
use,  namely,  a  narrow  pelvis,  is  of  but  of  very  rare  occurrence. 

•  Dr.  Davis,  (Elem.  Oper.  Mid.)  appears  to  have  used  the  forceps  when  the 
head  was  above  tlie  superior  strait;  and  recommends  it  with  every  apparent 
confidence,  in  sevei-al  cases  where  immediate  delivery  may  be  necessary.  This 
however,  neither  diminishes  the  difficulty,  nor  lessens  the  danger  of  these  instru- 
ments, when  awkwardly  used.  In  his  hands,  the  forceps  may  relieve  the  head 
from  any  situation  in  which  it  may  be  placed:  but  it  must  be  recollected  that 
few  can  boast  of  his  experience,  or  adroitness. 


GENERAL  REMARKS  ON  THE  USE  OF  THE  FORCEPS,  &C.    307 

I  have  been  obliged  to  use  Iheni  but  five  times  in  this  situation 
of  the  head,  in  more  than  forty  years;*  my  experience,  of  course, 
in  this  necessity,  is  very  limited.  On  this  account  especially,  I 
refer  to  the  high  authority  just  mentioned,  and  forbear  to  give  di- 
rections for  their  use.  I  believe,  that  the  frequent  mention  of  dif- 
ficult, dangerous,  and  rare  operations,  leads  oftentimes  to  the  un- 
necessary performance  of  them;  not  always  so  much  from  the 
necessity  of  the  case,  as  the  eclat  which  attends  them,  however 
unsuccessful.  In  surgery,  I  have  known  it  to  happen  more  than 
once:  and  once  certainly,  in  midwifery. 

833.  When  necessity  obliges  us  to  deliver  when  the  head  is  si- 
tuated at  the  superior  strait,  it  is  much  better  to  have  recourse  to 
the  doubtful,  but  safer  alternative  of  turning — for  it  will  rarely 
happen,  that  this  cannot  be  performed  while  the  head  remains 
free  above  the  superior  strait,  even  where  the  pelvis  may  be  a 
little  contracted,  with  at  least  as  much  safety  to  the  child,  and 
certainly  more  to  the  mother, t  I  should  therefore  earnestly  re- 
commend to  every  unskilled  practitioner,  not  to  attempt  this  diffi- 
cult, nay,  in  such  hands,  dangerous  operation.  Even  Smellie J  him- 
self, the  original  projector  of  the  use  of  the  forceps  at  the  superior 
strait,  deprecates  their  employment  at  this  part  of  the  pelvis;  he 
says,  "  a  long  pair  of  forceps  may  take  such  firm  hold,  that,  with 
great  force,  and  the  strong  purchase,  the  head  may  be  delivered, 
(from  the  superior  strait,)  but  such  violence  is  commonly  fatal  to 
the  woman,  by  causing  such  an  inflammation,  and  perhaps  lace- 
ration of  the  parts,  as  is  attended  with  mortification.  "  In  order," 
continues  he,  "  to  disable  young  practitioners  from  running  such 
risks,  and  to  free  myself  from  the  temptation  of  using  too  great 

*  It  is  a  little  remarkable,  that  I  was  under  tlie  necessity  lately  of  using'  the 
forceps  twice  within  ten  days  of  each  other,  when  the  head  was  at  the  siif  Jerior 
strait. 

t  Dr.  Davis  proposes  to  dehver  from  the  superior  strait,  under  cfrcumstances 
not  recognized  by  any  other  practitioner.  He  observes,  "  Ir  profuse  uterine 
haemorrhage,  for  instance,  the  orifice  of  the  uterus  being  «-ipposed  to  be  amply 
dilated,  but  the  head  of  the  child  still  at  the  brim  of  th^  pelvis,  this  method  of 
treatment  might  sometimes  very  well  deserve  consit'eration,  in  comparison  with 
dehvery  by  turning."— jEZem.  Oper.  Mid.  p.  23.'?. 

I  have  already  noticed  this  opinion  of  Dr.  Davis,  elicited  by  other  considera- 
tions oftliis  subject,  at  par.  657.  I  there  suggested,  and  now  repeat,  that  the 
use  of  the  forceps  under  such  circumstances,  mustbe  uncertain,  if  not  danger- 
ous; and  I  must  again  declare,  I  tliink  turning  to  be  the  proper  operation,  if 
necessary  to  have  recourse  to  any. 

+  Treatise,  Vol.  I.  p.  221. 


308  OF  THE  LOCKED  OR  IMPACTED  HEAD. 

force,  I  have  always  used  and  recommended  the  forceps  so  short 
in  the  handles,  that  they  cannot  be  used  with  such  violence  as 
will  endanger  the  woman's  life."  From  this  it  would  appear, 
that  even  in  the  hands  of  one  of  the  most  expert  accoucheurs, 
that  ever  lived,  there  was  much  danger  attending  delivery  by  the 
forceps,  while  the  head  remained  at  the  superior  strait. 


CHAPTER  XXIII. 

OF  THE  LOCKED  OR  IMPACTED  HEAD. 

834.  When  the  head  has  advanced  some  distance  into  the  pel- 
vis, and  cannot  proceed  farther,  and  when  it  is  immovable,  ex- 
cept upward  in  the  pelvic  cavity,  it  is  then  said  to  be  locked  or 
impacted.  Baudelocque's  account  of  this  situation  of  the  head,  is 
by  far  the  most  lucid  I  have  met  with  ;  he  most  successfully  com- 
bats the  opinions  of  Levret  and  Rocderer  upon  the  mechanism  of 
this  arrest  of  the  head,  and  completely  establishes  his  own  doc-> 
trines  upon  this  point.  1  have  so  rarely  met  with  this  situation 
of  the  head,  that  I  feel  almost  altogether  indebted  to  him  for  what 
I  know  upon  the  subject;  1  shall  therefore  adopt  his  account  of 
this  embarrassing  case.* 

835.  He  admits  but  one  general  species  of  locking,  and  that  is 
where  the  head  is  fixed  by  two  points  of  its  surface  diametrically 
opposite  each  other;  this  species  he  divides  into  two  varieties; 
1st,  where  the  head  is  jammed  with  its  greatest  length  between 
the  pubes  and  sacrum;  and,  2d,  where  its  thickness  cannot  pass, 
owing  to  a  narrowness  of  the  pelvis;  in  the  first  case,  it  is  the 
foreheaa  ^and  occiput  which  are  in  contact  with  the  inner  edge  of 
the  pelvis;  u-ad  in  the  second,  it  is  the  parietal  protuberances — 
this  latter  is  thernost  rare. 

836.  Whenever  Jie  head  becomes  locked,  it  acquires  the  form 
of  a  wedge;  Lamotte  finely  illustrates  it,  by  comparing  it  to  the 
keystone  of  an  arch. 

*  Madame  Le  Chapelle,  Velpeau  informs  us,  has  never  met  with  a  case  of 
locked  head. 


INDICATIONS  IN  THE  LOCKED  HEAD.  309 

Sect.  I. — Of  the  Causes,  Signs,  and  Occidents  of  the  Locked 
Head. 

837.  Several  causes  must  concur  to  produce  the  locked  head; 
1st,  the  long-continued  and  vehement  action  of  the  uterus,  and 
the  auxiliary  powers  of  labour — therefore,  this  fixedness  of  the 
head  never  need  be  feared  in  a  delicate  woman,  agreeably  to 
Baudelocque;  2d,  a  disproportion  between  the  pelvis  and  the 
head;  this  disproportion  may  depend  upon  the  mal-situation  of 
the  head,  upon  its  great  size  and  solidity,  or  upon  the  deformity 
of  the  pelvis. 

838.  The  immobility  of  the  head  is  the  pathognomonic  sign  of 
its  being  locked;  but  after  it  has  become  fixed,  other  symptoms 
arise,  which,  if  they  do  not  characterize  this  situation,  are  sure  to 
accompany  it — such  as  a  swelling  of  the  hairy  scalp  of  the  child, 
a  thickening  of  the  os  uteri,  an  intumescence  of  the  vagina,  and 
external  parts.  These  symptoms  do  not  always  declare  a  locked 
head,  but  a  locked  head  is  never  without  them.  When  the  pelvis 
is  so  small  that  the  head  cannot  engage  in  it,  certain  symptoms 
take  place,  which,  agreeably  to  Lamotte  and  Roederer  are  some- 
times mistaken  for  the  signs  of  a  locked  head. 

839.  A  locked  head  is  always  serious  to  both  mother  and  child; 
the  mother  it  exposes  to  inflammation,  sloughing,  or  gangrene ; 
and  the  child  to  almost  certain  death. 

840.  The  whole  of  the  soft  parts  of  the  mother  become  injured, 
by  the  long-continued  and  violent  pressure  which  the  child's  head 
exerts  upon  them;  the  vagina,  rectum,  and  urethra,  sometimes 
receive  irreparable  injury.  The  bladder  also  suffers  from  the  ac- 
cumulation of  the  urine,  nor  can  it  be  relieved  by  the  catheter, 
as  the  canal  of  the  urethra  is  entirely  obliterated. 

Sect.  II. — Indications  in  the  Locked  Head. 

841.  The  principal  indication  in  the  locked  head,  is  the  deli- 
very of  the  child.  This  is  to  be  effected  by  thp  forceps,  in  pre- 
ference to  any  other  means,  so  long  as  the  child  is  living;  if  its 
death  be  certain,  the  crotchet  undoubtedly  merits  the  preference. 
If  we  consult  the  older  writers  upon  this  subject,  we  shall  find 
they  all  had  recourse  to  the  crotchet  upon  such  occasions;  and  I 
am  sorry  to  add,  that  too  many  living  authors,  as  well  as  practi- 
tioners, are  too  fond  of  recommending  or  following  their^xample. 
For,  though  the  forceps  do  not  always  ensure  safety  to  the  child. 


310  INDICATIONS  IN  THE  LOCKED  HEAD. 

they  give  it  at  least  the  best  possible  chance;  they  should,  there- 
fore, always  be  preferred.  In  this  country,  this  terrible  case  is 
certainly  very  rare;  this  is  owing  principally  to  the  healthy  con- 
struction of  the  pelves  of  our  females.  When  it  lakes  place,  it 
almost  always  arises  from  the  bad  positions  of  the  head,  and  these 
positions  must  be  either  the  third  or  sixth — now,  these,  as  has  al- 
ready been  observed,  are  of  extremely  rare  occurrence. 

842.  I  especially  recommend  the  reader  to  consult  Baude- 
locque's  very  useful  chapter  upon  this  subject;  he  will  find  much 
excellent  practical  matter,  besides  the  histories  of  several  very 
interesting  cases,  which  are  of  much  more  importance,  particu- 
larly to  the  professed  accoucheur. 

843.  The  locked  head  is  sometimes  confounded  with  a  head 
merely  arrested  in  its  progress;  this  stoppage  may  arise  from, 
1st.  Whenever  the  head  maintains  its  diagonal  or  transverse  po- 
sition at  the  lower  strait;  2d.  When  the  chin  departs  from  the 
breast  too  early  in  the  labour ;  3d.  When  the  lower  strait  is  less 
than  the  ordinary  size ;  4th.  When  the  external  and  internal  parts 
make  much  resistance. 

844.  For  the  removal  of  the  first  cause,  we  must  bring  the 
vertex  towards  the  arch  of  the  pubes ;  by  one  blade  of  the  for- 
ceps or  by  a  lever ;  this  is  not  very  difficult  to  perform  ;  I  have 
succeeded  in  altering  this  position  of  the  head  by  applying  the 
extremity  of  the  instrument  upon  the  vertex,  by  passing  it  at  the 
bottom  and  side  of  the  pelvis,  until  it  has  passed  under  the  head; 
we  must  then  raise  the  edge  of  the  blade,  and  insinuate  it  between 
the  side  of  the  pelvis  and  the  vertex ;  then,  if  the  handle  be  press- 
ed against  the  perinzeum,  its  curve  will  be  placed  upon,  or  near 
the  posterior  fontanelle.  When  thus  fixed,  we  must  draw  the 
instrument  downward  and  forward  during  a  pain,  until  we  can 
move  the  vertex  to  its  proper  situation.  When  the  head  is  thus 
changed,  we  may  withdraw  the  vectis,  and  commit  the  rest  to 
nature. 

845.  The  mode  of  treating  the  second  case  has  already  been 
explained,  (702,  &c.)  when  speaking  of  this  perverse  situation  of 
the  head.  When  the  arrest  is  owing  to  the  smallness  of  the 
lower  strait,  as  in  the  third,  (843)  the  head  must  be  extracted  by 
the  forceps,  unless  the  defect  be  excessive;  and  if  excessive  and 
the  child  dead,  the  crotchet  must  be  used ;  but  if  living,  Baude. 
locque  proposes  the  Csesarean  operation.    If  the  external  and  inter- 


METHOD  OP  USING  THE  FORCEPS,  &C.  311 

nal  parts,  as  in  the  fourth  case,  (843)  offer  the  resistance,  blood- 
letting will  be  the  remedy. 

Sect.  III. — Method  of  Using  the  Forceps  in  the  Locked  Head. 

846.  When  the  head  is  locked  by  its  greatest  diameter  be- 
coming wedged  in  the  small  diameter  of  the  superior  strait,  it  is 
either  by  the  vertex  or  the  forehead  being  towards  the  pubes.  In 
using  the  forceps  for  either  of  these  situations,  we  must  conduct 
them  so  that  they  shall  apply  themselves  over  the  ears  of  the 
child,  or  to  the  sides  of  the  head.  They  must  be  so  arranged, 
that  the  concave  edges  must  be  towards  the  part  which  will 
eventually  come  under  the  arch  of  the  pubes.  When  the  head 
is  embraced,  we  must  endeavour  to  raise  it  up  by  a  compound 
motion  of  the  forceps;  that  is,  by  carrying  the  handles  gently 
from  side  to  side  of  the  pelvis,  and  at  the  same  time  pushing  the 
instruments  upwards,  so  as  to  raise  it  from  its  bed.  When  this  is 
done,  the  vertex  or  forehead  must  be  turned  towards  the  left  side 
of  the  pelvis,  if  practicable;  and  when  there,  the  motion  we  have 
already  described  must  be  given  to  the  handles  of  the  instru- 
ments, until  either  the  vertex  or  forehead,  as  the  case  may  be,  is 
brought  under  the  arch  of  the  pubes.  Baudelocqye  directs  the 
head  to  be  turned  as  it  is  brought  along,  but  I  do  not  think  this 
necessary;  for  when  the  head  arrives  at  the  inclined  plane,  form- 
ed by  the  sacro-ischiatic  ligaments,  it  will  turn  towards  the  open- 
ing of  the  pelvis  spontaneously.  It  must  be  recollected,  in  order 
that  the  instruments  should  be  carried  to  such  a  height  in  the 
pelvis,  that  the  handles  must  be  kept  well  pressed  against  the 
perincEum. 

847.  When  the  head  is  locked  by  the  small  diameter  becoming 
jammed  in  the  small  diameter  of  the  superior  strait;  the  vertex 
must  answer  to  either  the  right  or  the  left  side  of  the  pelvis,  and 
the  concave  part  of  the  instruments  must  look  towards  it;  conse- 
quently there  will  be  a  choice  of  blade  to  be  first  introduced — if 
the  vertex  be  to  the  left  side,  the  male  blade  must  be  first,  and  the 
reverse.  The  head  must  be  raised  from  out  of  the  superior  strait 
by  the  hand,  and  then  the  instruments  must  be  directed  over  the 
sides  of  the  head,  and  the  traction  must  be  in  conformity  with  the 
axis  of  the  upper  strait;  this  direction  is  given  by  pressing  the 
handles  against  the  perinseum. 


312 


CHAPTER  XXIV. 


OP  THE  USE  OF  THE  FORCEPS  IN  FACE  PRESENTATIONS. 

848.  In  considering  face  presentations,  I  was  inclined  to  re- 
strict their  number  to  two,  instead  of  four,  as  described  by  Bau- 
delocque — if  I  should  not  be  correct  in  this  reduction,  I  am 
at  least  sure,  that  the  first  and  second  of  my  arrangement,  are  by 
far  the  most  frequent,  and  can  safely  say,  I  have  never  met  with 
the  third  and  fourth,  though  they  were  recognized  by  both  Smel- 
lie  and  Baudelocque.  Indeed  the  presentation  of  the  face  in  any 
position  is  of  very  rare  occurrence;  I  find  I  have  met  with  it  but 
ten  times  in  more  than  ten  thousand  cases;*  and  upon  consulting 
the  table  furnished  by  "I'Hospice  de  la  Maternite  de  Paris,"  I 
find,  that  of  12,751  women  delivered  in  that  institution,  there 
were  but  forty  face  presentations;  and  of  that  forty,  but  one  of 
the  first  presentations  of  Baudelocque,  and  not  one  of  the  second; 
whereas  of  the  third,  there  were  twenty-two,  and  seventeen  of 
my  second.  This  is  strong  confirmation  of  the  infrequency  of 
the  first  and  second  positions  of  Baudelocque. 

849.  When  a  labour  in  which  the  face  presents  becomes  com- 
plicated by  any  of  the  before  enumerated  causes;  (651)  or  if  it  is 
rendered  impracticable  without  the  application  of  adventitious 
aid,  from  mere  position;  and  that  aid  consist  in  the  proper  appli- 
cation of  the  hand,  and  it  prove  insufiicient  for  its  accomplishment, 
we  must  resort  to  instrumental  delivery — this  will  comprehend, 
the  use  of  the  vectis,  the  application  of  the  forceps,  or  the  em- 
ployment of  the  crotchet. 

850.  Of  the  mode  of  using  the  vectis  I  have  already  spoken ;t 

*  It  is  a.  little  remarkable,  that  lately  I  met  with  two  cases  of  face  presenta- 
tion within  a  week  of  each  other,  and  a  third  witliin  tlu-ee  months  of  these  two; 
making-  nearly  half  the  number,  I  have  ever  encountered. 

f  Raudelocque's  method  of  using  the  lever  in  this  case,  ( System,  Vol.  HI.  par. 
1836,)  appears  to  me  to  be  defective,  as  I  have  already  stated.  I  have,  in  a  few 
instances,  used  as  described  before  with  the  most  decided  advantage — but  how 
far  it  may  be  successful  as  a  general  practice,  I  have  yet  to  learn;  for  I  .igain 
declare,  my  experience  in  face  cases  to  be  very  limited;  but  it  appears  to  me  to 


USE  OF  THE    FOKCEPS  IN  FACE   PKESENTATIONS.  313 

the  forceps  I  consider  of  doubtful  efficacy,  not  so  much  from  the 
difficulty  of  application,  as  their  mode  of  action  in  these  particu- 
lar cases;  though  it  would  seem,  Smellie  had  succeeded  with 
them.  I  would,  however,  wish  to  be  understood,  in  speaking  of 
the  use  of  these  instruments,  that  I  confine  my*  observations  en- 
tirely to  the  two  first  presentations  of  the  present  arrangement,* 
or  where  the  head  is  situated  ti-ansversely  in  the  pelvis.  In  such 
situations  of  the  face,  wc  are  told,  by  both  Smellie,  ai\d  Baude- 
locque,  "  that  we  must  use  the  forceps;"  the  latter  declaring,  that 
*'  when  we  cannot  rectify  the  relation  of  the  face  to  the  pelvis 
by  the  plan  already  advised,  or  without  great  danger  to  the  mo- 
ther, because  the  head  is  strongly  wedged,  and  the  uterus  con- 
tracted and  closed  upon  the  child," — "  we  must  use  the  forceps 
to  bring  the  head  along  in  the  attitude  we  find  it  in,"  because  few- 
er inconveniences  result  from  it  to  mother  and  child  than  Ironi 
any  other  method. 

851.  Should  the  forceps  be  determined  on,  we  must  apply  them 
over  the  ears;  that  is,  one  blade  behind  the  pubes,  and  the  other 
before  the  sacrum;  they  must  be  so  applied  that  the  concave 
edges  must  look  towards  the  hind  head,  which  must  be  brought 
under  the  arch  of  the  pubes,  and  not  the  chin,  as  directed  by 
Smellie. 

852.  Should  all  the  reasons  exist  for  using  the  forceps,  and  their 
application  not  prove  successful,  I  feel  that  this  is  one  of  the  very 
few  cases,  where  the  application  of  the  crotchet  is  justifiable  for 
the  preservation  of  the  mother,  however  repugnant  I  may  be  to 
its  use,  or  however  revolting  it  may  be  in  its  consequences. 

853.  Having  considered  all  the  most  frequent  and  better  known 
presentations  of  the  head,  with  the  v^arious  modes  of  conducting 
them  when  nature  is  sufficient  to  their  accomplishment;  the  mode 

be  more  consonant  witli  the  principle  to  be  acted  upon  in  such  cases;  which  is 
to  reduce  the  vertex,  and  elevate  tlie  chin.  But  agreeably  to  him,  we  must  act 
forcibly  upon  the  vertex,  that  it  may  "be  sufficiently  broug'lit  down;"  but  we 
cannot  bring  the  vertex  down  alone  by  his  plan,  as  the  face  will  descend  with  it 
by  obeying  the  same  impulse  which  moved  the  vertex.  Now,  this  disadvantage 
is  avoided  by  the  plan  I  propose;  namely,  after  fixing  the  vectis  properly  upon 
the  occiput,  we  apply  no  more  force  to  it  than  is  sufficient  to  prevent  it  from 
rising  in  the  pelvis,  at  the  lime  we  are  acting  on  the  face,  by  applying  two 
fingers  immediately  at  the  extremity  of  the  nose,  and  upon  the  upper  jaw. 

*  The  third  and  fourth  are  so  rai-e,  or  rather  their  possibihty  so  doubtful,  that 
I  do  not  think  it  worth  while  to  notice  them  farther  than  I  have  already  done — 
those  desirous  of  seeing  all  that  can  be  said  upon  these  positions,  are  referred 
to  Smellie,  and  Baudelocque. 
40 


314  USE  OF  THE  FORCEPS  IN  FACE  PRESENTATIONS. 

of  operating  by  the  hand  alone  Avhen  she  is  incompetent  to  this 
end,  and  the  use  of  instruments  when  it  becomes  essential  from 
this  cause  to  employ  them;  I  shall  not  consume  the  reader's  time 
or  patience  by  describing  a  variety  of  other  presentations  of  this 
part  as  laid  down  by  authors;  first,  because  I  never  have  seen 
them;  and,  second,  because  I  believe  if  they  really  exist,  they 
must  all,  or  with  very  few  exceptions,  be  treated  by  turning:  as 
I  shall  direct  for  many  other  rare  and  perverse  positions  which 
the  child's  body  may  assume  at  the  orifice  of  the  uterus, 

854.  Nor  shall  I  spend  time  in  describing  the  form  of  the  vectis, 
or  its  mode  of  application;  because  the  one  would  be  totally  un- 
necessary without  the  other  ;  and  I  decline  the  latter,  because  I 
am  not  in  the  habit  of  using  this  instrument,  except  in  rectifying 
bad  positions  of  the  head;  and  for  this  purpose  I  have  always 
found  one  of  the  blades  of  the  forceps  sufficient.  I  consider  the 
vectis  inferior  to  the  forceps,  in  power,  safety,  and  convenience: 
and  I  am  truly  glad  to  perceive  the  change  which  has  taken  place 
in  the  public  mind,  since  the  accurate  and  elaborate  analysis  of  its 
merits,  by  the  judicious  Baudelocque,  has  been  before  the  public. 

855.  T  am  also  pleased  to  find  a  change  in  Mr.  Burns'*  opinion 
upon  the  subject  of  the  vectis;  he  says  that  a  *'  young  practitioner 
shall  be  less  apt  to  injure  his  patient,  and  less  likely  to  be  foiled, 
with  the  forceps  than  the  vectis;"  and  particularly  gratified  that 
Dr.  James,  in  a  note  to  this  paragraph,  expresses  the  same  belief. 
The  latter  gentleman's  opinion,  upon  this  and  every  other  point 
connected  with  our  subject,  is  highly  valuable;  especially  in  this 
country,  where  the  opportunities  to  test  the  respective  merits  of 
these  instruments  can  fall  to  the  lot  of  no  one  who  is  not  exten- 
sively, and  for  a  long  period,  engaged  in  obstetrics;  for  the  facility 
of  labours  among  our  females,  owing  to  the  almost  entire  exemp- 
tion from  rickets,  and  other  causes  which  render  this  process  one 
of  much  more  difficulty  in  Europe,  give  comparatively  few  oppor- 
tunities to  decide  upon  their  respective  claims. 

856.  I  have  for  many  years  felt  the  superiority  of  the  forceps 
over  the  vectis;  but  was  reluctant  publicly  to  express  it,  from  an 
apprehension  that  I  might  have  mistaken  my  own  mal-adroitness 
in  using  the  latter,  for  an  imperfection  in  the  instrument  itself; 
but  strengthened  by  the  opinion  of  Dr.  James,  I  have  no  longer 
any  hesitation  upon  this  subject. 

*  Principles,  James's  ed.  1823,  Vol.  I.  p.  447. 


315 
CHAPTER  XXV. 

PRESENTATIONS  OP  THE  BREECH. 

857.  The  presentation  next  in  frequency  is  that  of  the  breech, 
though  not  so  arranged  by  Baudelocque;  but  as  I  before  stated,  I 
think  it  a  good  rule,  to  treat  of  labours  in  the  order  of  their  fre- 
quency. The  breech  may  with  great  propriety  be  considered  as 
a  variety  of  natural  labour;  since,  the  woman  most  frequently  is 
able  to  relieve  herself,  if  we  except  perhaps,  a  first  child;  though 
the  process  may  be  longer,  and  more  painful,  than  when  the 
vertex  presents  in  one  of  its  best  manners.  And  were  I  to  insti- 
tute a  comparison  between  the  two,  I  should  say  it  is  not  ordina- 
rily more  painful  than  the  fourth,  or  fifth  vertex  presentation.  I 
think  also,  that  this  presentation  is  more  favourable  for  the  child, 
than  either  the  feet  or  knees;  especially,  in  first  labours;  though 
the  operation,  generally  speaking,  is  slower;  and  perhaps  more 
fatiguing  to  the  mother. 

858.  The  risk,  in  all  the  labours,  whether  natural  or  artificial, 
in  which  the  child's  body  is  first  delivered,  arises  from  the  delay 
in  the  delivery  of  the  head,  and  the  compression  of  the  umbilical 
cord.  Now,  the  latter  very  frequently  depends  upon  the  former; 
and  the  former  upon  the  bad  position  of  the  head  as  regards  the 
pelvis;  or  from  the  rigidity  of  the  external  parts.  This  being  the 
case,  it  is  evident,  that  the  risk  from  the  delay  of  the  head  at  the 
inferior  strait  in  consequence  of  the  want  of  dilatation  of  the  ex- 
ternal parts,  must  be  less  in  presentations  of  the  breech,  than  in 
the  presentations  of  the  feet  and  knees;  because,  its  bulk  being 
nearly  equal  to  that  of  the  head,  will  by  passing  through  those 
parts  so  effectually  dilate  them,  as  very  much  to  diminish  the 
risk  of  such  delay.  On  this  account,  1  think  breech  labours,  csete- 
ris  paribus,  safer  to  the  child  than  those  of  the  feet  or  knees, 
though  they  are  not  generally  so  considered.* 

•  Baudelocquef  says,  that  "delivery  may  be  generally  performed  as  naturally 
when  the  child  presents  the  breech,  as  when  it  offers  the  feet  or  knees;  only 
that,  cseteris  paribus,  it  will  be  a  little  longer,  and  more  difficult;  because  the 
child  does  not  then  form  so  regular  and  lengthened  a  wedge,  as  when  the  lower 
extremities  are  unfolded."  I  agree,  tliat  it  may  be  "a  Uttle  longer  and  more 
difficult"  to  the  mother;  but,  for  the  reasons  above  stated,  I  think  it  safer  for 
the  child, 

t  System,  Vol.  I.  par.  7&6. 


316  MECHANISM  OP  THE  FIRST 

859.  The  presence  of  the  breech  at  the  orifice  of  the  uterus, 
cannot  be  very  well  ascertained  or  distinguished,  before  the  mem- 
branes are  ruptured  and  the  uterus  pretty  well  dilated.  Under 
proper  circumstances  it  may  be  known,  by  its  forming  a  large 
softish  tumour  in  the  pelvis,  which  wants  the  characters  of  the 
head,  with  which  it  is  alone  liable  to  be  confounded;  for  it  has 
neither  the  sutures,  nor  the  hardness  of  this  part;  nor  the  rough- 
ness of  the  hairy  scalp.*  A  deep  groove  is  observed  in  the  centre 
of  this  part,  which,  when  traced,  leads  to  the  detection  of  the 
anus,  and,  the  parts  of  generation.  A  discharge  of  meconium,  af- 
ter the  membranes  have  given  way,  tends  to  corroborate,  but  does 
not  absolutely  confirm  the  presence  of  the  breech,  t 

Sect.  I. — Species  of  the  Breech  Presentations. 

860.  There  are  four  principal  manners  in  which  the  breech 
may  present  at  the  upper  part  of  the  pelvis;  a,  the  first  is  where 
the  lower  part  of  the  spine  and  sacrum  offers  to  the  left  acetabu- 
lum, while  its  abdomen  looks  towards  the  right  sacro-iliac  sym- 
physis; by  2nd,  where  the  back  part  of  the  child  answers  to  the 
right  acetabulum,  and  the  belly  to  the  left  sacro-iliac  junction;  c, 
3d,  where  the  spine  and  sacrum  are  behind  the  symphysis  pubis, 
and  the  belly  towards  the  projection  of  the  sacrum;  d,  4th,  the 
reverse  of  this. 

Sect.  II. — a.  Mechanism,  of  the  First  Presentotion  of  the 
Breech. 

861.  In  this  presentation  Ihe  oblique  situation  of  the  breech  at 
the  upper  strait,  is  soon  changed  by  the  contraction  of  the  uterus, 
into  one  almost  strictly  transversal;  so  that  the  spine  will  at  one 

*  It  must,  however,  be  confessed,  that  there  is  sometimes  a  great  deal  of 
difficulty  in  deciding  whether  the  presentation  be  the  head  or  the  breech— the 
former,  when  veiy  much  swoln  by  becoming  locked,  may  resemble  the  breech; 
and  the  latter,  when  very  tumid,  may  have  its  principal  signs  so  masked,  as  to 
render  it  doubtful  whether  it  be  breech  or  head.  Baudelocquet  tells  us  of  an 
experienced  practitioner,  who  mistook  the  breech  for  a  locked  head,  and  de- 
livered it  with  the  forceps.  In  all  cases  of  ambiguity,  I  have  constantly  made 
it  a  practice  to  introduce  the  hand,  to  ascertain  the  nature  of  the  presentation 
whenever  it  becomes  important  to  decide  the  point. 

f  It  is  Levret,  I  think,  who  mentions  a  case  in  which  there  was  a  considera- 
ble dischai'ge  of  meconium,  thongli  the  head  presented;  and  I  am  certain  of 
having  met  with  one  case,  if  not  more,  of  a  similar  kind. 
\  System,  Vol.  I.  par.  1251. 


PRESENTATION  OP  THE  BREECH.  317 

time  be  found  behind  the  symphysis  pubis;  but  soon  after,  the  left 
hip  or  spine  of  the  ilium,  will  be  made  to  offer  itself  under  the  arch 
of  these  bones,  while  the  right  will  be  resting  upon  a  part  of  the 
sacrum,  and  the  inclined  plane  formed  by  the  left  sacro-ischiatic 
ligaments.  The  spine  of  tlie  child  will  rest  against  the  left  leg  of 
the  pubes,  and  the  hip  which  is  under  the  arch  will  rise  upwards, 
while  the  right  will  turn  into  the  hollow  of  the  sacrum,  and  tra- 
vel successively  over  the  point  of  the  coccyx  and  the  face  of  the 
perinajum,  to  offer  itself  at  the  bottom  of  the  vulva,  that  it  may 
escape  through  the  external  parts;  which  presently  it  does,  with 
the  other  portions  of  the  breech,  by  rising  by  a  slight  bend  of  the 
spine  towards  the  mons  veneris. 

862.  When  the  breech  has  passed  a  sufficient  distance  through 
the  OS  externum,  the  legs  of  the  child  fall  down;  and  the  remain- 
ing portion  of  the  body  by  the  successive  contractions  of  the  ute- 
rus will  be  delivered  by  passing  a  little  obliquely  through  the  ex- 
ternal opening  of  the  pelvis.  When  the  armpits  descend  to  the 
superior  strait,  there  is  a  momentary  interruption  to  the  farther 
descent  of  the  body  of  the  child,  occasioned  by  the  size  of  the 
shoulders,  and  position  of  the  arms  ;  but  from  the  pliant  disposi- 
tion of  these  parts,  it  is  but  temporary;  for  they  are  made  to  ac- 
commodate themselves  to  the  shape  of  the  pelvis,  by  the  repeated 
contraction  of  the  uterus.  -The  head  now  offers  itself  to  the  up- 
per opening  of  the  pelvis,  the  occiput  is  behind  the  left  acetabu- 
lum, and  the  face  before  the  right  sacro-iliac  junction.  The  chin 
will  descend  sooner  than  the  occiput,  in  consequence  of  its  having 
been  placed  against  the  breast  of  the  child. 

863.  As  soon  as  the  head  clears  the  superior  strait,  the  fore- 
head inclines  towards  the  hollow  of  the  sacrum,  by  the  same  pivot- 
like motion  which  it  performs  to  place  the  vertex  under  the  arch 
of  the  pubes,  in  vertex  presentations.  The  nape  of  the  neck  will 
now  be  under  the  arch  of  the  pubes,  while  the  face  will  be  Ivino- 
on  the  face  of  the  perinseum.  The  chin  will  first  escape  from  the 
vulva:  the  other  parts  of  the  face,  and  anterior  part  of  the  head, 
will  successively  follow;  while  the  nape  of  the  neck  will  execute 
a  slight  circular  motion  under  the  arch  of  the  pubes.  The  arms 
are  liberated,  so  soon  almost  as  the  shoulders  arc  pushed  through 
the  OS  externum.* 

•  It  must  be  borne  in  mind,  tliat  a  strictly  natural  delivery  is  here  described 
— or  in  other  ^\'ords,  where  no  advcTititious  aid  is  required. 


318  SECOND,  THIRD  AND  FOURTH 

Sect.  III. — b.  Mechanism  of  the  Second  Presentation  of  the 
Breech. 

864.  In  this  presentation,  the  mechanism  is  precisely  the  same 
as  that  of  the  first;  on  the  part  of  the  child  we  must  only  substi- 
tute the  right  hip,  offering  at  the  arch  of  the  pubes,  for  the  left, 
as  in  the  first  presentation;  and,  at  the  last  period  of  the  labour, 
the  vertex  or  occiput  will  be  placed  at  the  right  side  of  the  pelvis 
instead  of  the  left.  On  the  part  of  the  pelvis,  it  is  the  right  aceta- 
bulum, behind  which  the  breech  offers,  &c. 

Sect.  IV. — c.  Mechanism  of  the   Third  Presentation  of  the 
Breech. 

^%^.  In  this  presentation,  the  breech  engages  in  the  superior 
strait,  with  its  greatest  width  parallel  to  its  large  or  transverse 
diameter — the  spine  passes  immediately  behind  the  symphysis 
pubis;  and  it  becomes  a  matter  of  some  uncertainty,  which  hip 
will  ofller  under  it;  but  whichever  it  may  be,  it  passes  through  a 
little  obliquely,  as  in  the  other  presentations.  Though  in  this 
position  the  face  of  the  child  looks  directly  to  the  projection  of  the 
sacrum,  it  seldom  happens  that  the  head  becomes  jammed  with 
its  greatest  diameter,  in  the  small  diameter  of  the  superior  strait; 
it  is  therefore,  almost  always,  found  to  place  itself  diagonally,  and 
pass  down  in  that  direction,  as  in  the  two  former  presentations. 

866.  When  the  breech  becomes  free,  the  labour  proceeds  com- 
monly as  has  been  described  in  the  first  or  second  positions,  as 
it  may  be  the  left  or  the  right  hip  which  offers  to  the  arch  of  the 
pubes. 

Sect.  V. — d.  Mechanism  of  the  Fourth  Presentation  of  the 
Breech. 

867.  The  only  difference  in  the  mechanism  of  the  third  and 
fourth  of  these  presentations,  is,  that  instead  of  the  face  being 
placed  below,  as  in  the  third,  it  is  found  to  be  looking  up,  which 
creates  the  only' peculiar  diflicult}'  in  this  case.  The  risk  of  the 
head  engaging  with  its  greatest  length  in  the  smaller  diameter  of 
the  superior  strait,  is  perhaps  greater  in  this  than  in  the  third — 
but  should  this  take  place  in  either,  difficulty  might  be  created. 
The  fourth  presentation  is  decidedly  a  rare  one — I  have  met  with 
it  but  once  ;  and  upon  examining  the  retui'nsfrom  "I'Hospicede 


PRESENTATIONS  OF  THE  BREECH.  319 

Ja  Malernite,"  but  one  case  is  recorded  in  more  than  12,000. 
When  it  occurs,  and  we  have  not  lost  the  opportunity,  we  should 
always  seek  for  the  feet,  and  deliver  by  them. 

868.  I  have  already  observed,  that  all  the  presentations  of  the 
breech  are  attended  with  slower,  and  more  painful  labours;  and 
that  the  child  very  frequently  suffers.  This  is  especially  the  case 
where  tlie  labour  has  been  improperly  interfered  with,  either  by 
rupturing  the  membranes  unseasonably,  or  under  the  influence  of 
false  principles,  seeking  the  feet,  and  causing  the  child  to  pass 
rapidly  through  the  external  parts,  before  they  are  properly  re- 
laxed; in  consequence  of  this,  the  head  becomes  wedged  in  the 
inferior  strait.  Then,  under  the  direction  of  the  same  erroneous 
views,  it  is  attempted  to  deliver  it  quickly,  by  making  force  sup- 
ply the  place  of  address;  and  the  child  becomes  the  victim  of 
this  unnecessary,  and  ill-directed  violence. 

8G9.  It  must  constantly  be  recollected,  in  all  cases  in  which 
the  head  is  the  last  part  to  be  delivered,  that  when  it  offers  itself 
to  the  OS  externum,  it  is  entirely  from  under  the  direct  control 
of  uterine  action;  the  auxiliary,  and  voluntary  powers  alone  have 
an  influence  on  it  at  this  period  of  labour;  and  though  external 
force  may,  and  almost  always  does  become  necessary  to  termi- 
nate the  labour,  it  must  always  be  made  to  co-operate  with  these 
powers,  by  soliciting  the  woman  to  exert  them  as  amply  as  may 
be  in  her  power. 


CHAPTER  XXVI. 

CAUSES    WHICH    MAY    RENDER    PRESENTATIONS    OF    THE    BREECH 
PRETERNATURAL. 

870.  The  presentation  of  the  breech,  like  any  other  presenta- 
tion, may  be  complicated  by  either  of  the  accidents  enumerated 
in  par.  651,  and  must  when  thus  complicated  be  interfered  with, 
whenever  such  a  combination  may  render  the  labour  difficult  or 
dangerous. 

871.  Besides  the  causes  just  alluded  to,  there  n)ay  be  others 
connected  with  the  child  itself,  which  should  cause  us  to  aid  in 
the  delivery  of  the  woman.     But  in  the  absence  of  such  causes, 


320  PRESENTATIONS  OP  THE  BREECH. 

and  especially,  in  a  first  labour,  the  process  should  be  left  to  the 
powers  of  nature  alone;  or  at  least,  until  the  breech  is  delivered. 
872.  I  am  aware  that  many  respectable  practitioners  are  in  the 
habit  of  introducing  the  hand  and  bringing  down  the  feet,  in  all 
cases  of  breech  presentation;  but  I  am  abundantly  convinced, 
that  as  a  general  rule,  it  saves  the  mother  nothing,  and  that  it  is 
highly  dangerous  to  the  child.     I  am  of  opinion  that  this  prac- 
tice is  often  the  result  of  the  classification  of  labours,  as  breech 
presentations  are  almost  uniformly  placed  in  the  preternatural 
class ;  it  has,  therefore,  been  too  easily  supposed  that  such  cases 
always  require  extrinsic  aid.     May  not  this  be  one  of  the  rea- 
sons, why  so  many  children  perish  in  this  presentation?     What 
the  general  practice  in  breech    presentations  may  be  in  Great 
Britain,  I  am  not  prepared  to  say;  but  the  result  is  extremely 
unfavourable;  since  Dr.   Denman  says,  "I  have  considered  one 
child  in  three  of  those  born  with  these  presentations,  to  be  still- 
born."    This  proportion  by  no  means  coincides  with  my  experi- 
ence in  such  cases;  the  average  of  living  children  would  be  con- 
siderably greater,  though  a  number  of  my  cases  were  second 
hand,  and  in  which  the  first  stages  of  labour  had  been  very  often 
ill  conducted ;  I,  nevertheless,  think  Portal's  proportion  rather 
too  little  for  France,  where  there  must  necessarily  be  very  many 
faulty  pelves  to  contend  with,  as  he  makes  but  twenty  per  cent, 
while  Dr.  Denman's  is  thirty-three— in  this  country,  where  we 
but  very  rarely  meet  with  a  deformity  of  pelvis;  when  there  is 
not  an  excess  of  size  in  the  breech ;  and  when  the  earlier  stages 
of  labour  have  not  been  disturbed,  by  ill-timed  officiousness,  or. 
an  entire  ignorance  of  the  correct  rationale  of  such  cases,  I  am,  I 
think,  warranted  in  saying,  that  the  number  of  still-born  children 
from  breech  presentations,  niight  be  reduced  to  very  few.     But 
the  result  of  cases  in  which  the  breech,  the  knees,  or  the  feet 
present,  agreeably  to  the  records  of  '■'■la  Maternite,^^  is,  that 
one  child  in  eight  perishes,  which  is  again  very  much  less  than 
the  proportions  established  by  Denman  and  Portal  and  can  per- 
haps  only   be  satisfactorily  accounted   for,   by   supposing   that 
in  that  institution  a  better  treatment  is  established  for  these  cases. 
Yet  we  confess  on  the  other  hand,  that  the  proportion  of  still- 
born children  in  the  same  hospital,  to  those  born  alive  is,  judg- 
ing by  my  own  experience,  excessive;  namely,  one  in  thirty-two. 
In  this  counti-y,  under  favourable  management  we  do  not  think 
there  is  one  in  fifty,  if  we  select,  as  v/e  think  we  should,  only  such 


PUESENTATIONS  OF  THE  BREECH.  33). 

cases  in  which  children  die  in  the  birth,  and  this  we  presume  is 
the  mode  of  calculation  in  Paris,  as  the  comparison  is  instituted 
between  the  head,  breech,  feet,  and  knees,  cases.  This  disparity, 
induced  M.  Baudelocque,  nephew  to  the  celebrated  accoucheur, 
to  inquire  into  the  cause,  which  he  declares  to  be  always  the 
same;  namely,  to  the  interruption  of  circulation  between  the 
mother  and  child,  which  constantly  produces  a  sanguineous 
congestion,  either  in  the  brain  or  in  the  liver,  and  thus  adopt- 
ing the  opinions  of  Chausier,  Madame  Lachappelle  and  Duges. 

He  does  not  agree  with  his  uncle,  that  the  stretching  of  the 
vertebral  column,  is  a  frequent  cause  (736)  of  death  in  other, 
than  head  presentations,  and  strengthens  the  general  position,  by 
the  testimony  of  Mdme.  Lachappelle,  who  declares  she  has  seen 
children  born  alive,  when  so  much  force  had  been  applied  as  to 
cause  a  cracking  noise  from  the  tearing  of  the  ligament,  of  the 
cervical  ligaments.  But  let  us  not  be  deceived  upon  this  point, 
and  be  disposed  to  believe,  that  the  severe  stretching  of  the  cer- 
vical vertebrae  is  free  from  danger  to  the  child;  on  the  contrary, 
we  are  certain,  that  if  it  be  severe,  it  is  always  fatal  to  the  child, 
though  it  may  not  be  the  only  cause  of  its  death. 

873.  But  should  any  one  of  the  accidents  which  may  disturb 
a  labour,  assail  a  woman  whose  child  is  presenting  the  breech, 
we  are  justified  in  giving  such  assistance  as  the  exigency  of  the 
case  may  demand.  The  kind  of  aid  we  are  to  give,  will  depend 
upon,  1st.  a.  The  degree  of  advancement,  or  the  part  of  the  pelvis 
at  which  the  breech  may  be  at  the  time;  2d.  b.  The  position  of 
the  child ;  and  3d.  c.  The  size  of  the  breech. 

a.  First  degree  of  Advancement . 

874.  An  accident  threatening  or  endangering  the  life  of  the  mo- 
ther, may,  a,  attack  her  in  the  very  commencement  of  labour, 
and  where  the  child  is  still  at  the  superior  strait;  b,  it  may  attack, 
when  the  breech  is  pretty  low  in  the  pelvis,  but  still  included  by 
the  uterus;  c,  it  may  attack  when  the  breech  is  at  the  lower 
strait,  but  escaped  from  the  uterus. 

875.  a.  This  may  happen  when  the  uterus  is  well  dilated,  or 
easily  dilatable,  or  when  rigid;  the  membranes  may  be  either 
entire  or  just  ruptured,  or  ruptured  a  long  time. 

876.  Should  any  circumstance  render  it  necessary  to  deliver 
the  woman  when  labour  is  but  little  advanced;  the  breech  at 
the  superior  strait,  or  near  it;  the  uterus  dilated  or  dilatable;  the 

41 


322  CAUSES  RENDERING  BREECH  PRESENTATIONS 

membranes  entire  or  just  ruptured:  we  must  without  hesitation 
introduce  the  hand  and  bring  down  the  feet,  and  finisli  the  deli- 
very as  directed,  when  turning  is  employed  for  a  vertex  presen- 
tation. But  should  the  uterus  be  still  shut,  or  but  little  opened 
and  rigid,  nothing  should  tempt  us  to  enter  the  uterus  forcibly, 
with  a  view  to  bring  down  the  feet  and  deliver;  especially,  if 
the  membranes  are  entire ;  as,  under  such  circumstances,  there 
must  be  a  reasonable  expectation  that  the  uterus  will  soon  dilate, 
at  least  sufficiently  to  pass  the  hand  without  violence.  As  I  have 
constantly  inculcated  the  impropriety  of  dilating  the  uterus  by 
force,  whenever  the  labour  is  complicated  by  any  supervening 
accident,  I  must  be  understood  to  make  no  exception  here  in  fa- 
vour of  this  presentation;  therefore,  when  the  uterus  is  rigid, 
and  but  little  opened,  we  must  treat  Ihe  case  by  temporising 
agreeably  to  the  nature  of  the  accident,  until  either  the  remedies, 
or  the  influence  of  the  accident,  or  the  powers  of  the  uterus  it- 
self, shall  make  such  change  as  will  render  the  attempt  at  bring- 
ing down  the  feet  proper  and  safe. 

b.  Second  Degree  of  Advancement. 

Sn.  b.  It  may  attack  when  the  breech  is  pretty  low  in  the 
pelvis,  but  still  included  in  the  uterus;  this  may  happen  when  the 
uterus  is  well  dilated  or  easily  dilatable,  or  when  rigid  and  un- 
yielding; and  when  the  membranes  are  entire  or  just  ruptured; 
or  when  the  waters  have  been  drained  off  a  long  time,  and  the 
uterus  is  firmly  embracing  the  body  of  the  child. 

878.  In  the  first  instance,  or  where  the  uterus  is  in  a  condition 
to  transmit  the  hand  without  much  force,  the  membranes  entire, 
or  the  waters  but  lately  passed  off,  we  should  bring  down  the 
feet  as  directed  in  the  former  instance,  and  finish  the  labour  after 
the  same  manner.  But  should  the  os  uteri  be  rigid,  whether  the 
membranes  be  entire  or  not,  we  must  not  force  the  mouth  of  the 
uterus,  with  a  view  to  terminate  the  labour;  but,  as  just  suggest- 
ed, temporise,  until  the  uterus  will  permit  the  hand  to  pass  for 
this  purpose,  without  difficulty;  for  it  will  rarely  happen,  even 
where  the  waters  have  long  escaped,  that  we  cannot  pass  the 
hand  to  the  margin  of  the  pelvis,  and  seize  the  feet,  provided  the 
proper  hand  be  employed. 

c.  Third  Degree  of  Advancement. 

879.  c.  It  may  attack  when  the  breech  is  at  the  lower  strait, 
but  passed  through  the  mouth  of  the  uterus.     This  situation  ne- 


PRETERNATURAL,  AND  MOBE  OF  TREATMENT.      323 

cessarily  presupposes  the  dilation  of  the  uterus,  and  ahnost  cer- 
tainly the  escape  of  the  waters.  In  this  condition  of  the  breech 
and  uterus,  we  must  not  attempt  to  bring  down  the  feet,  unless 
the  breech  be  very  small,  or  the  pelvis  very  ample,  and  the  wo- 
man without  pains,  or  at  least  efficient  ones:  for  if  they  are  pro- 
trusive, and  under  the  circumstances  just  mentioned,  they  will 
deliver  the  breech  in  good  time,  or  in  such  time  as  will  prevent 
any  serious  inconvenience  from  the  delay.  But  should  the  breech 
be  large,  and  occupy  the  lower  strait  very  strictly,  we  should  not 
attempt  to  finish  the  labour  by  bringing  down  the  feet.  In  this 
case,  we  must  assist  the  passage  of  the  breech,  by  acting,  1st, 
with  the  fingers;  2d,  by  the  fillet;  3d,  by  the  blunt  hook  or 
hooks. 

SSO.  When  the  breech  is  very  low  in  the  pelvis,  or  so  low  that 
w^e  can  place  a  finger  into  the  groin,  we  may,  by  the  forces  so  ap- 
plied, aid  the  descent  of  the  breech;  especially,  if  the  uterus  by 
its  contractions  still  powerfully  co-operate  with  our  exertions. 
Whenever  attainable,  we  should  prefer  that  groin  which  is  most 
posterior  to  the  arch  of  the  pubes,  when  but  one  at  a  time  can  be 
operated  on.  If  both  groins  can  be  reached,  we  may  insinuate  a 
finger  of  each  hand  into  them,  and  have  this  double  power  to  as- 
sist the  breech  to  descend. 

851.  Should  the  force  just  directed,  be  too  feeble  for  the  pur- 
pose ;  or  too  fatiguing  to  the  operator,  he  may  substitute  the  fil- 
let with  very  great  advantage.  Baudelocque*  makes  a  disparaging 
mention  of  this  power;  he  says,  "its  application  is  so  difficult, 
that  it  is  with  a  sort  of  repugnance  that  he  reckons  it  among  the 
resources  of  art."  That  it  is  sometimes  difficult  in  its  application, 
I  readily  admit ;  but  it  is  by  no  means  impracticable,  when  the 
breech  occupies  the  lower  strait.  If  the  passing  of  the  fillet  be 
attempted  when  the  breech  is  pretty  remote  from  the  os  exter- 
num, we  may  certainly  be  foiled ;  but  this  is  not  a  case  proper 
for  this  instrument;  for  it  can  only  be  used  when  the  point  of  the 
finger  can  command  the  groin. 

852.  This  fillet  should  consist  of  a  piece  of  silk  riband  of  an 
inch  and  a  quarter  or  half  wide,  and  at  least  two  feet  and  a  half 
long.  When  doubled,  the  point  of  the  forefinger  must  be  placed 
in  the  centre  of  the  fold  and  kept  tight  upon  it,  by  drawing  k 
sufficiently  with  the  other  hand — the  parts  of  the  woman  and 

*  System,  par.  1267. 


324  CAUSES  RENDERING  BREECH  PRESENTATIONS 

the  fillet  should  both  be  imbued  with  lard  or  sweet  oil,  and  the 
riband  then  passed  into  the  vagina  by  the  point  of  the  finger, 
and  conducted  over  the  hip,  and  into  the  groin  towards  the  parts 
of  generation  of  the  child,  as  far  as  the  point  of  the  finger  can 
reach;  the  finger  is  then  to  be  retracted  a  little,  that  it  may  ga- 
ther upon  its  point  another  fold  or  fillet,  which  it  also  carries 
forward  as  far  as  it  can  reach;  and  this  to  be  repeated  for  seveiral 
times,  until  the  folds  so  multiply  in  the  groin  as  to  move  each 
other  forward,  so  as  to  appear  at  the  other  extremity  of  it — when 
there,  it  may  be  drawn  down  by  the  forefinger  of  the  other  hand, 
introduced,  after  the  first  is  withdrawn  from  the  vagina;  or  it  may 
be  hooked,  as  proposed  by  Baudelocque,  and  as  1  have  myself 
practised,  by  a  hook,  made  extemporaneously,  of  a  piece  of  pret- 
ty stiff  wire. 

8S3.  When  the  fold  of  the  fillet  is  seized  by  the  finger  and 
thumb,  or  hooked  by  the  instrument  just  mentioned,  we  are  to 
take  hold  of  one  of  the  outer  extremities  of  it  with  one  hand, 
while  we  draw  the  other  end  through  the  groin,  by  gaining  suc- 
cessive portions  of  it.  When  the  fillet  is  thus  made  single  in  the 
groin,  we  take  hold  of  both  extremities  of  the  riband,  and  secure 
a  good  hold  by  passing  it  several  times  round  some  of  the  fingers. 
We  then  co-operate  with  the  pains  if  there  be  any,  by  pulling  in 
the  direction  of  the  axis  of  the  lower  strait,  until  the  breech  is  re- 
lieved from  the  pelvis.  But  if  the  pains  have  ceased,  we  draw 
at  intervals;  at  the  same  time,  we  solicit  the  co-operation  of  the 
patient. 

884.  But  should  we  not  be  able  to  pass  the  fillet,  because  the 
breech  is  too  remote  from  the  finger;  or,  because  the  breech  is 
very  large,  and  firmly  impacted  in  the  pelvis,  we  must  then  at- 
tempt assistance,  by  employing  the  blunt  hook,  or  hooks.  I  have 
found,  more  than  once,  the  hook  at  the  extremities  of  the  French 
forceps  answer  extremely  well,  as  Baudelocque  long  since  sug- 
gested. But  that  they  may  be  employed  with  advantage,  they 
must  stand  very  nearly  at  right  angles  with  their  stems;  for  if 
they  are  too  much  depressed,  they  cannot  be  introduced  into  the 
groins;  for  this  reason  I  would  advise  every  gentleman  who  may 
adopt  these  instruments,  to  attend  to  this  circumstance  at  the 
time  he  is  purchasing  them. 

885.  The  mode  of  using  the  blunt  hook,  is  by  first  placing  the 
point  of  the  forefinger  upon  the  groove  which  leads  to  the  groin: 
then  pass  the  handle  of  the  forcep  into  the  vagina,  with  the  point 


PRETERNATURAL,  AND  MODE  OF  TREAT^MENT.  325 

of  the  hook  looking  upward  or  towards  the  point  of  the  inserted 
finger,  until  it  comes  in  contact  with  it;  then,  by  altering  the 
position  of  the  hook,  and  making  it  take  the  place  of  the  finger, 
by  a  gentle  pressure,  it  may  be  placed  in  the  groin;  when  thus 
placed,  we  must  aid  the  descent  of  the  breech  by  pulling  at  the 
external  extremity  of  the  instrument  in  the  direction  of  the  axis 
of  that  part  of  the  pelvis  through  which  the  breech  is  to  pass. 

886.  Baudelocque  proposes  blunt  hooks  to  join  something  like 
tlie  forceps  for  this  operation ;  but  this  I  do  not  think  necessary; 
for  when  both  groins  can  be  commanded,  and  it  is  essential  from 
the  nature  of  the  difficulties  attending  the  labour  to  act  upon  both 
of  them  at  the  same  time,  both  handles  of  the  forceps,  I  am 
of  opinion  may  be  employed  advantageously,  without  being 
united — but  I  confess  this  to  be  conjecture;  for  I  have  had  no 
experience  of  it. 

887.  When  the  breech  is  situated  obliquely  at  the  lower  strait, 
w^e  should  apply  the  force  whenever  practicable,  to  the  groin 
wliich  offers  to  the  sacro-iliac  symphysis,  or  side  of  the  sacrum; 
as  this  hip  should  advance  faster  than  the  other,  that  it  may  ar- 
rive at  tlie  bottom  of  the  vulva  to  escape  through  the  os  exter- 
num. When  placed  transversely,  we  may  act  upon  either,  or 
both  groins,  until  the  breech  is  about  to  pass  under  the  arch  of  the 
pubes — when  there,  we  should  endeavour  to  depress  one  of  the 
groins,  that  the  ilium  may  come  under  the  arch,  instead  of  the 
sacrum  and  spine,  unless  it  does  so  spontaneously. 

Sect.  I. — 1.  Position  of  the  Child. 

888.  The  child  may  present  so  untowardly  at  the  superior 
strait,  in  consequence  of  a  severe  obliquity  of  the  uterus,  as  to 
be  unable  to  engage  in  it.  In  such  case,  one  of  the  hips  may 
only  present  itself  to  the  opening  of  the  pelvis;  of  course  the  la- 
bour, if  not  rectified  by  changing  the  position  of  the  woman,  will 
be  very  tedious  and  painful,  or  even  dangerous.  This  situation 
of  the  hip  will,  of  itself,  offer  great  embarrassment  to  the  woman 
delivering  herself;  and  often  render  it  proper  that  we  inter- 
fere without  delay;  but  when  this  position  is  attended  with 
either  of  the  accidents  heretofore  enumerated,  it  becomes  indis- 
pensable that  we  bring  down  the  feet;  provided,  the  conditions 
on  the  part  of  the  uterus  just  mentioned,  do  not  render  that  ope- 
ration improper. 

889.  Should  the  breech  present  in  the  fourth  position,  and  this 


326  CAUSES  RENDEUTNG  BREECH  PRESENTATIONS 

be  ascertained  immediately  after  the  rupture  of  the  membranes, 
it  would  I  believe,  always  be  best  to  bring  down  the  feet;  pro- 
vided, the  uterus  be  sufficiently  relaxed  to  permit  the  hand  to 
pass  without  difficulty  ;  but  should  this  presentation  be  complica- 
ted by  any  accident,  it  will  become  absolutely  necessary;  but  it 
must  be  under  the  provisions  just  stated. 

Sect.  II. — 2.  Size  of  the  Breech. 

890.  The  breech  may  be  absolutely,  or  relatively  large  as  re- 
gards the  pelvis ;  in  either  case,  the  same  difficulties  will  be  ex- 
perienced. If  the  labour  be  left  to  itself,  it  may  consume  so 
much  of  the  w^oman's  strength  as  to  render  her  situation  pre- 
carious without  recourse  be  had  to  adventitious  aid.  This  case 
may  be  complicated  by  any  of  the  accidents  already  enumerated; 
or  its  difficulties  may  be  increased,  by  being  a  fourth  presenta- 
tion. 

891.  When  sufficient  time  has  been  given,  without  advantage 
to  the  labour;  and  the  cause  of  the  delay  satisfactorily  ascertain- 
ed, we  should  interpose  and  save  the  patient  much  unavailing  pain. 
The  nature  of  the  assistance  to  be  given  must  depend;  1st,  upon 
the  condition  of  the  uterus,  and  the  degreeof  advancement  of  the 
breech;  and  2d,  whether  it  be  still  contained,  or  has  escaped, 
from  the  mouth  of  the  uterus.  In  the  first  case  we  must  bring 
down  the  feet  so  soon  as  the  uterus  will  permit;  and  in  the  se- 
cond also,  provided,  the  breech  is  still  within  the  uterus;  and  the 
waters  but  recently  drained  off;  but  if  it  has  escaped  from  the 
orifice  of  the  uterus,  we  must  employ  the  fingers,  the  fdlet,  or  the 
blunt  hook,  as  may  appear  expedient. 

Sect.  III. —  The  Mode  of  bringing  doivn  the  Feet,  in  the  First 
Presentation  of  the  Breech. 

892.  The  success  of  this  operation  very  much  depends  upon 
-the  choice  of  the  hand  to  be  employed.  The  rule  on  this  subject 
is  extremely  simple — the  hand,  the  palm  of  which  will  answer  to 
the  anterior  parts  of  the  child,  is  always  to  be  used.  In  this 
presentation  then,  the  left  hand  will  be  the  proper  one  for  bring- 
ing down  the  feet.  It  must  be  introduced  with  due  attention  to 
the  rules  already  laid  down,  when  speaking  of  turning,  and  pass- 
ed upward  before  the  right  sacro-iliac  symphysis,  until  it  can  grasp 
the  breech — which  must  be  raised,  and  carried  into  the  left  iHac- 
fosse.    We  must  then  search  for  the  feet,  by  tracing  the  posterior 


PRETERNATURAL,  AND  MODE  OF  TREATMENT.      327 

part  of  the  thighs  and  legs,  until  we  arriveat  them;  they  must  be 
seized  as  before  directed,  and  brought  down. 

893.  If  but  one  foot  can  be  obtained,  we  may  attempt  the  de- 
livery, by  acting  upon  it  alone;  but  when  practicable,  it  is  best 
to  search  for  the  other,  unless  it  will  require  too  much  force.  It 
will  rarely  happen  if  the  breech  be  small,  that  much  diiliculty 
will  be  experienced  in  doing  this;  but  this  is  precisely  the  case 
in  which  we  can  almost  always  succeed,  by  applying  the  force  to 
one.  When  delivering  by^^one  foot  only,  we  should  be  very  mind- 
ful of  the  direction  in  which  we  act  upon  it — we  should  al- 
ways direct  our  force  so  as  to  carry  the  leg  towards  the  retained 
one,  lest  we  fracture  or  dislocate  the  thigh;  and,  when  the 
folded  leg  begins  to  appear,  we  may  assist  it  by  acting  with  a 
finger  on  the  groin.  When  the  breech  is  without,  we  must  con- 
duct the  body  along,  until  the  other  leg  and  foot  falls  down  of 
itself. 

894.  When  the  breech  is  still  within  the  uterus,  and  occupies 
the  lower  strait,  we  can  very  often,  should  the  necessity  of  the 
case  require  it,  gain  the  feet,  and  enable  us  to  expedite  the  la- 
bour; provided  the  waters  have  not  been  too  long  drained  off; 
the  pains  feeble;  and  if  the  breech  is  not  of  an  unusual  size.  But 
if  the  breech  has  passed  the  os  uteri,  we  must  not  think  of  this 
expedient — when  thus  situated,  the  fingers,  the  fillet,  or  the  blunt 
hook,  must  be  our  aids. 

Sect.  YV.—  The  Mode  in  the  Second  Presentation  of  the  Breech. 

895.  A  proper  choice  of  the  hand  must  be  made  in  this  pre- 
sentation, as  well  as  in  the  preceding — when  the  emergency  of 
the  case  requires  bringing  the  feet  down,  we  must  make  use  of 
the  right  hand  instead  of  the  left,  and  conduct  the  rest  of  the  ope- 
ration in  every  respect  as  just  directed.  If  but  one  foot  can  be 
obtained,  we  must  proceed  with  it  to  finish  the  labour;  but  al- 
ways recollecting  the  conditions  which  would  render  this  partial 
action  safe  and  proper.  (893)  Should  the  breech,  however, 
have  escaped  from  the  mouth  of  the  uterus,  it  would  be  highly 
improper  to  pass  up  the  hand  with  a  view  to  bring  down  the  feet 
— the  aids  just  indicated  (879)  must  then  be  resorted  to. 

Sect.  Y .—  The  Mode  in  the  Third  Presentation  of  the  Breech. 

896.  The  spine  of  the  child,  in  this  presentation,  is  to  the  sym- 
physis pubis,  and  the  abdomen  to  the  projection  of  the  sacrum — 


328  CAUSES  RENDERING  BREECH  PRESENTATIONS,  &C. 

this  position  is  less  favourable  than  the  first  and  second,  owing  to 
the  risk  of  having  the  head  to  engage  with  its  greatest  length  pa- 
rallel to  the  small  diameter  of  the  superior  strait;  this,  however, 
is  not  a  necessary  consequence  of  this  presentation,  as  we  have 
already  observed. 

897.  In  this  presentation,  either  hand  may  be  used.  When 
required  to  act,  the  hand  must  take  a  firm  hold  of  the  breech,  as 
directed  for  the  raising  of  the  head,  and  carry  it  forward  and 
upward,  over  the  pubes,  and  then  pass  the  hand  along  the  legs, 
until  the  feet  can  be  reached;  they  must  now  be  brought  down, 
as  heretofore  directed;  only  observing,  when  the  feet  are  entirely 
without,  to  turn  the  breech  so  as  to  make  the  body  have  an  ob- 
lique position  as  regards  the  pelvis. 

Sect.  VI.—  The  Mode  in  the  Fourth  Presentation  of  the  Breech. 

898.  I  have  already  remarked  how  very  rare  this  presenta- 
tion is;  but  when  it  does  occur,  there  can  be  no  doubt  of  the  pro- 
priety, if  called  to  the  case  in  proper  time,  of  always  searching 
for  the  feet.  In  this  presentation,  either  hand  may  be  used,  as 
mentioned  for  the  third;  only  observing,  that  the  breech,  in  this 
case,  if  possible,  must  be  carried  to  one  of  the  iliac  fossae;  to  the 
right,  if  we  use  the  right  hand,  and  the  reverse,  that  the  body 
may  enter  the  superior  strait  obliquely,  so  as  to  give  the  chance 
to  the  face  to  turn  from  the  pubes — after  this,  we  search  for  the 
feet,  and  bring  them  down  as  directed.  When  the  breech  is 
without,  we  must  attempt  to  give  an  oblique  position  to  the  body, 
if  it  has  not  already  acquired  it.  It  does  not  necessarily  follow, 
however,  that  this  case  will  be  attended  with  more  difficulty 
than  those  just  spoken  of;  as  the  child  may  be  very  small,  or  the 
pelvis  very  ample.  In  either  instance  the  woman  would  be  ena- 
bled to  deliver  herself 

899.  It  may  be  proper  to  observe,  that  all  breech  cases  are  to 
be  subject  to  the  rules  I  have  endeavoured  to  inculcate  for  the 
safety  of  the  uterus:  1st.  That  no  severity  of  accident  can  justify 
forcing  a  passage  into  the  uterus,  with  an  intention  of  gaining  the 
feet  when  the  os  uteri  is  unyielding.  2d.  That  ^vhen  the  breech  is 
very  large,  the  waters  long  drained  off,  the  uterus  firmly  contract- 
ed on  the  body  of  the  child,  and  much  force  would  be  required, 
(whatever  address  the  accoucheur  may  possess,)  the  feet  must 
not  be  sought  for ;  but  the  labour  must  be  terminated  by  the  other 
agents  already  indicated.  (879)  3d.  But  when  the  uterus  is  in 


THE  USE  OP  THE  FORCEPS,  &C.  329 

proper  condition,  and  the  membranes  just  ruptured,  or  the  con- 
tractions not  severe,  though  the  waters  may  have  escaped  some 
time,  we  should  lose  no  time  by  temporizing,  when  the  accident 
is  of  a  nature  to  render  interference  important  to  mother  and 
child. 


CHAPTER  XXVII. 

THE  USE  OF  THE  FORCEPS  WHEN  THE  BODY  OF  THE  CHILD  IS  DE- 
LIVERED, AND  THE  HEAD  RETAINED. 

900.  The  risk  the  child  always  runs  when  its  body  is  deliver- 
ed first,  is  so  great,  as  to  make  us  look  upon  such  labours  as 
hazardous,  whether  the  necessity  for  this  consideration  be  natural- 
ly or  artificially  created.  I  have  already  adverted  to  this;  but  it 
may  still  be  useful  to  repeat,  that  the  danger  to  the  child  arises, 
1st.  From  the  severe  extension  to  which  the  cervical  vertebrae  may 
be  liable,  when  it  is  necessary  to  employ  force  for  the  deliverance 
of  the  head;  2d.  The  almost  inevitable  compression  of  the  cord, 
if  th«e  head  be  large,  either  positively  or  relatively,  as  it  will  be 
caught  almost  necessarily  between  the  head  and  pelvis,  or  if  it  be 
tightly  stretched,  by  its  passing  between  the  legs  of  the  child, 
and  we  are  unable  to  relieve  it,  &c.  These  causes  pretty  con- 
stantly operate,  where  the  head  is  the  last  part  to  be  delivered, 
unless  the  pelvis  be  very  ample,  or  the  head  small,  and  the  exter- 
nal parts  disposed  to  yield  readily,  and  the  mechanism  of  this  part 
of  the  labour  well  understood.  The  mode,  by  which  the  remote 
causes  just  enumerated  effect  the  death  of  the  child  is  not  so  clearly 
understood  at  this  moment  as  it  should  be,  considering  its  import- 
ance; and  this  seems  to  be  admitted  on  all  hands,  and  will,  we 
trust,  elicit  farther  inquiry.  MM.  Baudelocque  (nephew  to 
the  celebrated  accoucheur)  and  Hervey  de  Chegoin,  have  offered 
some  valuable  observations,  in  "  a  Report  on  two  new  proposi- 
tions by  M.  Baudelocque,  junior,  for  preserving  the  life  of  the 
foetus  when  it  presents  the  breech,  feet,  or  knees,  made  to  the 
Royal  Academy  of  Medicine  by  M.  Hervey  de  Chegoin." 

We  think  these  observations  so  deserving  of  being  more  gene- 
rally known,  that  we  attach  them  to  our  text.  And  we  farther 
42 


330  THE  USE  OP  THE  FORCEPS 

think,  that  their  value  is  increased,  by  the  observations  of  Dr. 
Hodge  of  our  city,  who  has  prepared  the  paper  for  the  '<  Ameri- 
can Journal  of  Medical  Sciences  for  February,  1833,  page  463. 

"It  being  generally  acknowledged,  that  the  child  during  partu- 
rition is  much  more  endangered  when  it  presents  the  ^^elvic  than 
the  cephalic  extremity  of  the  foetal  ellipse,  the  question  as  to  the 
nature  and  cause  of  this  difference  is  of  importance.  M.  Baude- 
locque,  Jr.  in  a  late  communication  to  the  Royal  Academy  of 
Medicine,  maintains  that  the  cause  of  death  in  pelvic  presenta- 
tions is  alidays  the  same,  viz.  the  interruption  of  the  circulation 
from  the  mother  to  the  child^  and  that  the  effects  of  this  inter- 
ruption d^YQ  always  the  same,  viz.  a  sanguineous  congestion  in  the 
brain  and  liver,  with  or  without  effusion  at  the  bass  of  the  brain. 
He  considers,  therefore,  the  asphyxia  and  the  apoplexy  of  new- 
born infants,  to  be  two  degrees  of  the  same  state,  there  being  in 
both,  sanguine  congestion  of  the  brain  and  other  interior  organs. 

"  The  cause  of  the  interruption  of  the  circulation  between 
mother  and  child,  he  refers  exclusively  to  pressure  on  the  cord 
by  the  body,  but  especially  by  the  head  of  the  child  in  the  pelvis. 

"  Founded  on  these  views,  he  recommends  two  modes  of  pro- 
cedure in  cases  where  the  head  is  retained  after  the  delivery  of 
the  body;  and  the  child's  life  thus  jeopardized.  He  proposes  to 
divide  the  umbilical  cord,  and  allow  it  to  bleed;  and  then  to  ex- 
cite respiration  immediately,  even  while  the  head  may  be  in  utero. 
For  this  last  object,  he  suggests  the  use  of  a  long  silver  canula, 
with  numerous  perforations,  by  means  of  which  atmospheric  air 
may  penetrate  into  the  uterus,  and  also  of  a  shorter  canula  which 
may,  when  requisite,  be  introduced  into  the  mouth  of  the  foetus. 
In  eleven  infants,  presenting  the  feet,  the  umbilical  cord  was  di- 
vided as  soon  as  the  pulsations  became  feeble,  and  before  the  head 
was  delivered;  the  children  were  born  alive.  In  three  cases,  the 
division  of  the  cord  was  not  made,  and  the  children  were  born 
dead.  The  attempt  to  excite  respiration  was  not  made  in  either 
of  the  above  cases;  but  M.  Baudelocque  conceives  it  may  some- 
times be  requisite.  It  may  well  however  be  doubted,  whether 
respiration  can  possibly  occur  when  the  head  is  fixed,  as  the  case 
supposes,  in  the  superior  strait  of  the  pelvis.  But  that  respiration 
may,  under  peculiar  circumstances,  occur,  and  even  cries  be  eli- 
cited while  the  child  is  in  utero,  a  point  hitherto  much  disputed 
and  generally  denied,  seems  to  be  proved  by  an  experiment  of 
M.  Baudelocque.     In  the  case  of  a  face  presentation,  after  having 


WHEN  THE  BODY  OP  THE  CHILD  IS  DELIVERED,  &C.        331 

punctured  the  membranes,  he  passed  a  canula  into  the  mouth  of 
the  child,  and  inflated  the  lungs.  lie  and  his  assistants,  M.  Mar- 
tin, a  physician,  and  Madame  Chaumonot,  a  midwife,  distinctly- 
heard,  for  the  space  of  a  minute,  the  respiratory  noise.  The  infant 
was  eventually  delivered  alive  by  means  of  the  forceps. 

"  Giving  all  confidence  to  the  facts  reported  by  M.  Baudelocque, 
it  would  seem  that  in  some  cases  at  least,  it  would  be  useful  to 
divide  the  umbilical  cord  before  the  delivery  of  the  head,  to  re- 
lieve congestion,  and  to  prevent  effusion  and  death.  But,  can 
these  cases  be  always  ascertained?  may  not  the  child  perish  from 
the  loss  of  blood,  owing  to  the  time  required  for  the  delivery  of 
the  head?  and  especially  is  it  necessary  to  inquire  whether,  as 
M.  Baudelocque  supposes,  this  congestion  always  exists?  or 
whether  on  the  contrary,  it  be  not  often  true  that  the  child  is 
already  in  a  state  of  anemia,  where  the  loss  of  a  small  quantity  of 
blood  would  be  necessarily  fatal?  The  questions  also  arise  whether 
other  causes  may  not  be  operative  in  the  destruction  of  the  foetus, 
independent  of  interruption  of  the  placental  circulation;  and 
whether  such  interruption  depends  on  the  pressure  of  cord  as  has 
been  usually  supposed;  or  on  some  other  circumstance,  connect- 
ed with  pelvic  presentations? 

^'M.  Hervey  de  Chegoin,  in  a  report  to  the  Academy,  on  the 
communication  of  M.  Baudelocque,  has  noticed  several  of  the 
above  questions;  and  expressed  his  doubts  on  many  of  the  posi- 
tions assumed  by  the  author  of  the  essay. 

"  In  presentations  of  the  inferior  extremities,  and  of  course  in 
the  operation  of  version  by  the  feet,  do  not  foetuses  often  perish 
in  consequence  of  the  force  applied  by  the  accoucheur,  rather 
than  by  pressure  on  the  cord?  M.  Baudelocque  and  Madame 
Lachapelle  would  say,  no ;  because  they  have  met  with  cases 
where  great  force  had  been  exercised,  even  to  the  tearing  of  the 
vertebral  ligaments,  and  yet  the  child  has  survived.  The  report- 
er however  doubts  the  legitimacy  of  the  deduction,  when  the  re- 
sults of  cases  in  which  little  or  no  traction  has  been  exercised,  are 
compared  with  those  in  which  much  force  had  been  employed. 
Certainly  few  can  doubt  the  injurious  effects  of  traction  on  the 
lower  extremities  and  body,  in  cases  where  the  head  is  retained, 
and  the  consequent  danger  to  which  the  child  is  exposed;  espe- 
cially when,  as  is  not  unfrequently  the  case,  from  ignorance  or 
inattention,  the  neck  is  also  twisted.  The  only  wonder  which 
can  be  excited  is,  that  all  do  not  perish  under  this  management. 


332  THE  USE  OP  THE  FORCEPS 

Hence,  as  the  effect  of  traction,  when  the  head  is  entering  or  en- 
gaged in,  the  superior  strait,  is  almost  always  injurious  by  causing 
the  head  to  present  unfavourably,  the  practice,  however  general 
or  sanctioned  by  authority,  should  be  abandoned;  no  force  of  any 
amount  should,  at  this  stage  of  the  operation  at  least,  be  applied 
to  the  trunk  of  the  infant;  but,  if  any  resistance  be  required,  it 
should  be  judiciously  directed  to  the  head  itself. 

"  There  can  be  no  doubt  that  M.  Baudelocque  is  in  error  in 
referring  the  interruption  of  the  circulation  between  the  mother 
and  child,  in  all  cases  to  pressure  on  the  cord  alone;  for  as  the 
reporter  remarks,  in  pelvic  presentations  generally,  after  the 
trunk  is  delivered,  the  uterus  has  so  contracted  that  a  separation 
of  the  placenta  from  the  uterus  is  very  frequently  effected;  and 
in  some  cases,  especially  where  the  head  has  descended  into  the 
excavation,  the  uterus  may  be  emptied  not  only  of  the  child,  but 
also  of  the  placenta.  In  all  such  cases,  death  must  soon  occur 
from  the  cessation  of  the  placental  functions,  independently  of 
pressure  on  the  cord. 

"  What  is  the  result  of  compression  of  the  cord?  M.  Baude- 
locque contends  that  in  all  cases  the  result  is  plethora,  whence 
apoplectic  congestion  and  effusion  as  demonstrated  by  dissection. 
But,  says  the  reporter,  this  is  a  surprising  assertion;  for  if  the 
pressure  be  made  equally  on  the  vein  and  on  the  arteries  of  the 
cord,  the  foetus  it  is  true  no  longer  sends  blood  to  the  mother; 
but  also  no  longer  receives  any  from  the  mother  by  the  umbilical 
vein.  The  exit  of  blood  is  prevented,  but  the  supply  is  also  cut 
off;  therefore  there  can  be  no  increased  quantity.  M.  Chegoin 
however  carries  this  argument  much  further,  and  contends,  that 
as  the  circulation  of  blood  in  the  vein  is  effected  only  by  the 
agency  of  capillary  vessels,  while  the  passage  of  blood  through 
the  umbilical  arteries  is  facilitated  by  the  contractions  of  the  foetal 
heart,  it  follovvs  that  when  the  vessels  of  the  cord  are  equally 
pressed  upon,  the  course  of  blood  may  be  arrested  in  the  vein  but 
not  in  the  arteries  where  the  momentum  is  greater;  in  other 
words,  that  the  exit  of  blood  is  continued  while  the  supply  is  ar- 
rested. Hence,  the  foetus,  instead  of  being  plethoric,  may  actually 
perish  for  the  want  of  blood,  and  this  condition,  M.  Chegoin  in- 
timates, would  be  more  likely  to  ensue  when  the  placenta  was 
separated  from  the  parietes  of  the  uterus.  This  apparently  spe- 
cious theory  is  supported  by  the  well  known  fact,  that  children 
are  born  presenting  externally  very  different  appearances  under 


WHEN  THE  BODY  OP  THE  CHILD  IS  DELIVERED,  &C.        333 

the  circumstances  now  contemplated.  In  some,  the  child  is  livid 
and  swelled,  particularly  on  the  head,  neck,  and  chest;  the  cord 
is  large  and  tense,  and  on  being  cut,  the  blood  issues  with  much 
impetus.  In  others,  the  infant  is  pale  and  exhausted,  its  limbs 
flaccid,  features  contracted,  cord  small  and  pallid,  and  when  di- 
vided furnishing  little  or  no  blood.  The  former  is  regarded  as  a 
state  of  apoplexy;  the  latter  as  a  state  of  anemia,  of  syncope,  or 
asphyxia. 

"  We  must  however  dissent  from  the  idea  of  actual  plethora  or 
anemia  in  those  cases  where  death  suddenly  occurs,  the  mother 
and  child  having  been  previously  in  a  natural  and  healthy  condi- 
tion. Independent  of  many  facts  which  might  be  adduced  in 
opposition  to  these  theories,  both  opinions  seem  to  be  predicated 
on  an  erroneous  view  of  the  foetal  circulation:  viz.  that  the  blood 
of  the  foetus  passes  indirectly  by  means  of  the  umbilical  arteries 
and  maternal  veins  to  the  mother,  and  the  blood  of  the  mother 
indirectly  by  maternal  arteries  and  the  umbilical  vein  to  the  child; 
so  that  blood  might  be  lost  by  the  child  from  its  arteries  when 
the  supply  by  the  vein  was  arrested,  v^hence  anemia;  or,  that  the 
supply  might  be  continued  from  the  mother  while  the  exit  by 
the  arteries  of  the  cord  was  diminished  or  suspended,  whence 
plethora.  But  we  thought  that  these  views  had  been  abandoned 
by  good  physiologists.  There  is  satisfactory  proof  that  there  is 
no  direct  or  indirect  communication  between  the  blood  of  the 
mother  and  that  of  the  child.  The  latter  forms  its  own  blood  in 
utero  out  of  materials  furnished  by  the  parent,  as  certainly  as  the 
chick  forms  its  own  blood  in  ovo,  out  of  materials  there  provided. 
The  blood  from  the  umbilical  arteries  of  the  child  passes  to  the 
radicles  of  the  umbilical  vein,  and  not  those  of  the  maternal  ves- 
sels, and  hence  any  variety  of  pressure  on  the  arteries  or  vein  of 
the  cord  can  have  but  a  comparatively  trifling  influence  on  the 
quantity  of  blood  at  any  time  in  the  body  of  the  foetus. 

"  If  therefore  neither  plethora  nor  anemia  be  the  cause  of  death 
when  pressure  is  made  on  the  cord,  whence  the  source  of  mis- 
chief? Very  many  have  referred  it  to  the  simple  interruption  of 
the  circulation,  but  this  is  not  sufficient,  as  death  occurs  too  sud- 
denly to  admit  of  this  explanation;  and  moreover,  the  anatomical 
structure  of  the  foetus  is  such  as  to  allow  a  perfect  circulation  of 
blood  even  if  the  cord  be  completely  obstructed.  The  injury 
therefore  must  be  referred  to  some  other  source,  and  as  this  death 
occurs  suddenly,  and  is  usually  accompanied  with  great  venous 


334  THE  USE  OF  THE  FORCEPS 

congestion,  and  may  be  prevented  by  establishing  at  once  the 
respiratory  process,  it  may  be  referred  to  the  suspension  of  the 
purifying  influence  of  the  placenta  on  the  blood,  the  placenta  act- 
ing as  lungs  to  the  foetus — how  is  unknown.  Hence,  as  conges- 
tion of  venous  blood  follows  the  suspension  of  the  respiratory  pro- 
cess, congestion  follows  the  suspension  of  the  placental  influence, 
and  may  be  succeeded  by  the  efilision  of  blood  as  testified  by 
Eaudelocque  and  others.  It  is  difficult  however  to  account  for 
the  opposite  condition  of  the  foetus,  or  to  specify  the  particular 
circumstances  which  produce  a  state  of  congesf^Dn  or  syncope. 
There  are  wanting  a  very  careful  observation  and  collation  of 
facts  on  this  subject.  But  if  it  be  true  that  children  are  born  some- 
times in  the  one,  and  sometimes  in  the  other  condition,  the  prac- 
tice of  dividing  the  cord  in  all  cases  of  delay  must  be  very  dan- 
gerous, even  should  future  experience  confirm  the  recommenda- 
tion of  M.  Baudelocque  in  cases  where  congestion  can  be  demon- 
strated to  exist. 

"  Again:  should  the  hypothesis  of  the  author  be  correct,  that 
in  all  cases  of  asphyxia  of  new-born  infants,  there  is  congestion  of 
some  internal  organ  and  often  efiusion,  yet  the  practice  he  re- 
commends must  be  injurious,  as  the  general  circulatory  system 
is  depressed  and  emptied.  The  local  congestion,  in  such  cases, 
will  not  justify  general  depletion.  Infants  are  often  recovered  from 
this  state,  not  by  depletory  measures  to  which  none  resort,  but 
by  internal  and  external  stimuli  which  sympathetically  excite 
the  respiration  and  circulation. 

"  It  is  a  difiicult  matter  to  determine,  by  external  appearances, 
the  precise  condition  of  the  internal  organs  in  this  asphyxiated 
condition  of  new-born  infants.  Baudelocque  insists  that  conges- 
tion always  exists,  and  often  efiusion,  and  appeals  to  his  dissec- 
tions where  such  changes  were  invariably  perceived;  but  the 
condition  of  the  organs  after  death,  as  regards  their  vascular  ful- 
ness, is  no  certain  index  of  their  state  before  death;  and,  as  infants 
born  in  this  state  of  asphyxia  are  frequently  preserved  by  judi- 
cious and  persevering  efibrts,  we  must  conclude  that  such  conges- 
tion and  eff'usion  either  do  not  exist,  or  that  they  are  less  injuri- 
ous than  usually  supposed;  and  moreover,  that  stimulating,  not 
depletory  measures  are  suitable  in  such  supposed  cases  of  con- 
gestion. 

"  As  to  the  apoplectic  state  above  described,  all  will  unite  in 
the  importance  of  evacuating  the  blood — a  practice  commonly 


WHEN  THE  BODY  OP  THE  CHILD  IS  DELIVERED,  &C.         335 

resorted  to  and  which  may  be  employed  as  M.  Baiidelocque  re- 
commends, even  before  the  delivery  of  the  head.  An  additional 
remark  however  is  of  importance,  that  this  depletion  should  be 
followed  up  by  stimuli  to  the  surface,  nostrils,  rectum,  &c.,  as  in 
cases  of  asphyxia;  for  the  actions  of  the  heart  and  arteries  are 
feeble,  and  the  surface  cold  in  these  apoplectic  cases  evincing 
depression  of  arterial  action  with  the  fulness  and  turgescence  of 
the  venous  system.  Hence  while  we  empty  the  veins,  the  blood 
should  be  determined  to  the  arterial  system,  that  the  natural  ac- 
tions may  be  fully  re-established. 

"On  the  whole,  we  agree  with  the  reporter,  M.  Chegoin,  that 
death  in  pelvic  presentations  is  not  simply  the  result  of  pressure 
on  the  cord,  but  may  also  ensue  from  other  causes,  as  injury  to 
the  spinal  marrow,  detachment  of  the  placenta,  &c. ;  that  general 
plethora  does  not  exist  when  such  interruption  occurs;  neither, 
we  would  add,  is  there  any  deficiency  of  blood  in  the  foetus;  and 
that  in  a  practical  point  of  view,  the  states  of  asphyxia  and  apo- 
plexy are  so  far  different,  that  in  one  the  loss  of  blood  would  be 
injurious,  but  in  the  other  highly  useful.  We  believe  however 
that  these  cases  are  so  far  of  the  same  character,  that  in  both,  the 
arterial  circulation  is  depressed;  of  course,  the  phenomena  of  or- 
ganic life  diminished.  The  one  condition  may  be  regarded  as  a 
sinTple  state  of  asphyxia,  the  other  as  asphyxia  with  venous  con- 
gestion of  the  vital  viscera;  the  one  requiring  simple  but  appro- 
priate stimulation,  the  other  in  addition,  evacuation  of  venous 
blood,  to  relieve  oppression  and  facilitate  reaction  of  the  heart  and 
arteries." 

901.  These  considerations  early  engaged  the  attention  of  Smel- 
lie;  and  the  result  of  his  deliberations  was,  the  practicability  of 
applying  the  forceps  with  success  in  such  cases.  Accordingly,  he 
has  left  upon  record  his  method  of  employing  them,  and  the  suc- 
cess attending  it.  He  has  been  followed  by  De  Leurie,  Baude- 
locque,  and  others.  I  am  every  way  disposed  to  do  justice  to  the 
merit  of  this  application  of  the  forceps;  and  consider  it  as  a  real 
improvement  in  the  art,  whenever  their  application  is  guided  by 
experience,  or  their  employment  properly  limited. 

902.  It  will  be  readily  admitted,  by  all  who  have  attempted 
the  application  of  these  instruments,  with  a  view  to  relieve  the 
head  when  the  body  was  delivered,  that  it  is  attended  with  no 
inconsiderable  difficulty,  even  in  the  most  simple  of  the  cases  in 
which  the^may  be  required;  how  much  more,  then,  when  the 


336  CASES  PROPER  FOR  THE  FORCEPS. 

head  is  remote  from  the  inferior,  and  perhaps  tightly  wedged 
in  the  superior  strait;  in  both  of  which  cases  the  use  of  these  in- 
struments is  recommended.  1  did  not  succeed  in  the  two  or  three 
instances  in  which  I  employed  them,  under  the  circumstances  de- 
scribed by  Smellie  and  Baudelocque,  and  as  represented  by  the 
former  in  his  35th,  and  by  the  latter  in  his  14th  plate.  I  will  not 
say  that  their  application  is  impracticable 'because  I  failed;  espe- 
cially as  both  Smellie  and  Baudelocque  declare  they  have  suc- 
ceeded; but  there  are  several  serious  difficulties  to  oppose  their 
application  which  I  will  endeavour  to  point  out:  1st.  When  the 
head  of  the  child  is  at  the  superior  strait,  and  engaged  with  its 
greatest  length  between  the  pubes  and  sacrum,  or  even  when  the 
forehead  and  vertex  offer  to  the  sides  of  the  pelvis;  as  the  axis  of 
this  strait  is  so  much  in  advance  of  the  inferior,  that  it  seems  al- 
most impossible  that  the  perinseum  could  be  pressed  so  far  back, 
as  to  permit  the  forceps  to  correspond  with  it,  that  they  may  se- 
curely grasp  the  head;*  2d.  That  if  the  head  be  even  grasped  by 
the  forceps,  it  must  be  in  the  direction,  or  very  nearly  so,  of  the 
perpendicular  diameter  of  the  child's  head,  instead  of  the  oblique; 
a  circumstance  of  great  consequence  to  the  success  of  the  operation; 
3d.  This  advantageous  position  of  the  head  for  the  use  of  these 
instruments,  may  lead  to  the  belief  that  they  are  well  placed,  be- 
cause their  handles  unite  without  difficulty;  whereas,  they  but 
very  partially  embrace  the  head;  and  if  an  effort  be  made  to  ex- 
tract they  will  most  probably  slip,  and  the  uterus,  vagina,  or 
bladder,  be  severely  injured. 

Sect.  I. — Cases  j)Toper  for  the  Forceps. 

903.  From  these  considerations,  I  would  confine  the  use  of  the 
forceps,  in  the  cases  under  consideration,  to  two  situations  of  the 
head,  and  those  at  the  inferior  strait,  a.  The  first  when  the  ver- 
tex is  behind  the  symphysis  of  the  pubes,  and  the  face  resting  on 
the  face  of  the  perinaeum;  b.  The  second  when  the  forehead  is  be- 
hind the  symphysis,  and  the  vertex  lying  towards  the  hollow  of 
the  sacrum. 

a.  Mode  of  Operating  in  the  First  Case. 

904.  It  rarely  happens  that  the  forceps  are  indicated  in  this 

*  This  will  be  readily  understood,  when  it  is  recollected,  that  the  direction 
of  the  opening  of  the  superior  strait,  is  at  an  angle  of  about  30°,  and  conse- 
quently, its  axis,  and  that  of  the  inferior  strait,  do  not  coincide. 


CASES  PROPER  FOR  THE  FORCEPS.  337 

situation  of  the  head,  since,  when  it  arrives  here,  it  may  be  al- 
most always  delivered  by  soliciting  the  voluntary  powers  of 
the  woman;  by  depressing  the  chin;  and  by  a  judicious  force 
exerted  upon  the  trunk.  But  at  this  moment,  the  woman  may 
be  attacked  by  some  accident;  or  the  head  may  be  very  large, 
or  the  pelvis  narrow;  the  cord  may  be  in  danger  of  compression; 
the  woman  may  be  too  feeble  to  make  any  effort  to  relieve  her- 
self, and  it  might  require  too  much  force  for  the  safety  of  the 
child,  to  attempt  its  deliverance  by  the  body  alone,  yet  the  wel- 
fare of  it  may  require  immediate  delivery. 

905.  When  the  circumstances  of  the  case  will  most  probably  be 
improved  by  the  use  of  these  instruments,  we  should  apply  them, 
if  at  hand,  witliout  loss  of  time,*  in  the  following  manner;  the 
body  of  the  child  must  be  carefully  wrapped  up  in  a  cloth,  and 
carried  over  the  mons  veneris,  as  far  as  it  can  be  done,  without 
injury  to  its  neck,  and  supported  there  by  a  careful  and  judicious 
assistant;  the  chin  of  the  child  should  be  depressed,and  the  male 
branch  of  the  forceps  be  passed  to  the  left  side  of  the  pelvis  de- 
pressing the  handle  pretty  suddenly  against  the  perinaium;  this 
must  be  more  or  less,  as  we  may  find  it  necessary  to  make  the 
blade  conform  as  much  as  possible  to  the  oblique  diameter  of  the 
head;  when  this  is  arranged,  the  handle  must  be  sustained  until 
the  other  blade  is  passed  on  the  opposite  side  of  the  pelvis,  and 
made  to  correspond  with  its  fellow — the  handles  must  now  be 
locked,  and  drawn  in  such  direction  at  one  and  the  same  time,  as 
shall  tend  to  disengage  the  vertex  from  behind  the  pubes,  and  at 
the  same  instant  raise  the  face  along  the  perinseum,  until  the  chin 
and  other  parts  of  the  face  successively  pass  through  the  os  ex- 
ternum. 

*  It  might  on  some  accounts  be  proper  to  be  provided  with  these  instruments, 
whenever  we  have  leisure  to  send  for  them,  in  all  such  cases  as  we  cannot  de- 
cide positively  that  they  will  not  be  necessary.  I  was  once  made  very  happy 
by  having  them  with  me,  when  sent  for  to  the  aid  of  a  midwife.  The  patient 
was  pretty  far  advanced  in  life  before  slie  married;  she  had  lost  three  children 
previously,  and  was  now  in  labour  with  a  breech  presentation.  The  child  was 
very  lai-ge,  and  required  the  fillet — the  breech  I  deUvered,  the  body  followed, 
and  no  difficulty  was  experienced  until  the  head  was  stopped  at  the  inferior 
sti-ait,  hi  consequence  of  its  size.  I  employed  as  much  force  as  I  dared,  and 
the  woman,  exerted  herself  powerfully;  but  the  head,  though  well  situated, 
could  not  be  made  to  pass.  I  was  very  anxious  about  the  life  of  the  child,  and 
the  poor  mother  begged  that  I  might  save  it  at  any  expense  of  pain  to  herself, 
as  she  •'  had  lost  all  her  poor  babes  before."  1  determined  to  try  the  forceps,  as 
I  had  brought  them  with  me,  and  did  with  tlie  happiest  effect. 
43 


338  OF  THE  PKESENTATIONS  OF  THE  FEET. 

b.  Mode  of  Operating  in  the  Second  Case. 

906.  The  only  difference  in  the  mode  of  operating  in  this  case 
from  the  first,  (905)  is,  that  the  body  of  the  child  must  be  carried 
backward,  and  gradually  depressed  as  the  head  disengages  back- 
ward.* 


CHAPTER  XXVIII. 

OF  THE  PRESENTATIONS  OF  THE  FEET. 

907.  The  presentations  next  in  the  order  of  frequency,  are 
those  of  the  feet;  these  presentations  are  with  propriety  ranked 
among  the  natural  labours,  because  the  woman  is  enabled  to  de- 
liver herself.  Baudelocque  says  that  ''those  labours  in  which 
the  child  presents  the  feet,  considered  as  natural,  are  not  the  most 
advantageous;  but  as  preternatural,  they  must  be  esteemed  the 
easiest  and  the  most  favourable."  In  this  I  cannot  exactly  coin- 
cide, at  least  as  far  as  regards  the  safety  of  the  child,  which,  in 
my  opinion,  ought  always  to  enter  into  the  calculation;  for  its 
welfare  must  be  looked  upon  as  constituting  at  least  a  part  of 
what  is  to  be  understood  by  the  words  "most  favourable."  I 
have  elsewhere,  (858)  assigned  my  reasons  for  this. 

908.  Had  not  the  erroneous  principle  been  so  often  inculcated, 
and  still  more  frequently  acted  upon,  "  that  in  presentations  of 
the  feet,  not  to  deliver  the  woman  as  speedily  as  possible,  was  to 
exercise  a  cruelty  towards  her,  by  permitting  her  to  endure  hours 
of  pain,  when  it  was  in  our  power  to  relieve  her  in  a  very  short 
time,  by  exerting  a  force  by  the  feet,  which  would  speedily  de- 
liver the  body,"  we  should  have  had  fewer  instances  to  complain 
of  injuries  sustained  by  the  mother,  and  fewer  occasions  to  lament 
the  death  of  the  child. 

909.  It  should  be  held  as  a  fundamental  principle  in  this  va- 
riety of  labour,  and  all  the  others  enumerated  under  the  title  of 
natural,  that  they  must  be  considered  as  such  in  the  true  sense  of 
the  word,  at  least  until  the  uterus  is  dilated,  and  the  membranes 

*  Baudelocque  advises  the  forceps  in  these  cases,  when  the  child  is  dead,  in- 
stead of  the  crotchet. 


SPECIES  OP  FEET  PRESENTATIONS.  339 

are  ruptured,  and  after  these  have  taken  place,  only  to  consider 
them  as  preternatural,  or  labours  requiring  assistance,  when  they 
are  complicated  by  accidents,  or  when  their  progress  is  retarded 
b}^  causes  existing  in  the  uterus  itself,  or  from  the  position  of  the 
child.  Under  such  circumstances,  we  are  not  only  justified  in 
aiding  the  woman  in  her  struggles,  but  it  becomes  a  duty  to  do 
so,  in  the  best  and  most  efficient  manner,  the  case  will  admit. 
But  to  do  this  with  the  greatest  advantage  to  both  mother  and 
child,  requires  a  thorough  knowledge  of  the  mechanisms  of  these 
labours,  as  well  as  considerable  address  to  fulfil  the  various  indi- 
cations, their  different  positions  create;  that  the  former  need  not 
suffer  from  the  effects  of  ignorant  rashness,  or  the  latter  fall  a  vic- 
tim to  it. 

910.  The  presentations  of  the  feet  are  readily  distinguished 
from  all  others,  by  there  being  no  other  parts  of  the  child  which 
resemble  them;  the  hands  alone  bear  any  analogy;  but  from  them 
they  are  easily  told  by  the  projecting  heels,  the  short  toes,  and 
especially  by  the  absence  of  the  thumb.  Baudelocque,  whom  I 
shall  follow,  has  divided  presentations  of  the  feet  into  four  species 
— the  distinguishing  marks  of  each  being  derived  from  the  part 
of  the  pelvis  to  which  the  heels  and  toes  are  directed  ;  according- 
ly four  species  are  made. 

Sect.  I. — Species  of  Feet  Presentations. 

911.  In  the  first  presentation,  the  heels  are  a  little  anterior  to 
the  left  acetabulum,  and  the  toes  are  directed  towards  the  right 
sacro-iliac  symphysis;  the  breast  and  face  are  above  and  over  it, 
while  the  back  is  placed  to  the  anterior  and  left  lateral  part  of 
the  uterus.  It  may,  perhaps,  be  proper  to  remark,  that  in  these 
presentations,  the  feet  and  legs  do  not  hang  loose  or  dangle  in 
the  pelvis,  but,  on  the  contrary,  the  thighs  are  flexed  against  the 
abdomen,  the  legs  folded  against  the  thighs,  while  the  heels  are 
almost  always  placed  against  the  breech,  or  are  in  its  immediate 
vicinity.  1  thought  it  best  to  state  this,  that  the  difficulty  which 
is  sometimes  experienced  in  bringing  down  the  feet,  may  be  bet- 
ter comprehended.  It  must  be  also  borne  in  mind,  that  both 
do  not  always  present  at  the  same  time,  and  that  they  are  so 
movable  in  the  pelvis  oftentimes,  that  it  is  more  difficult  to  locate 
their  exact  position,  than  to  distinguish  it  is  the  feet,  that  are  pre- 
senting. 

912.  In  the  second  presentation,  the  heels  are  behind  the 
right  acetabulum,  or  a  little  forward;  the  toes  look  toward  the 


340  rUESENTATIONS  OP  THE  FEET. 

left  sacro-iliac  symphysis;  while  the  breast  and  face  are  above 
and  over  it;  the  back  is  placed  to  the  right  anterior  portion  of 
the  uterus. 

913.  In  the  third  presentation,  the  heels  are  to  the  symphysis 
pubis,  and  the  toes  toward  the  sacrum;  the  back  is  placed  to  the 
anterior  part  of  the  uterus,  while  the  breast  and  face  look  to- 
wards the  lumbar  column. 

914.  In  the  fourth  presentation,  the  position  of  the  child  is 
exactly  reversed;  the  heels  are  to  the  sacrum,  and  the  toes  to 
the  pubes;  the  back  towards  the  lumbar  column,  and  the  breast 
and  face  are  turned  towards  the  anterior  part  of  the  uterus. 

915.  Nature  seems  to  have  been  particular  in  the  arrangements 
of  the  presentations  of  the  breech,  feet,  and  knees,  by  making  the 
numerical  order  of  each  resolve  themselves  into  one  general 
position,  so  soon  as  the  legs  are  without;  so  that  the  most  favour- 
able situation,  or  the  first  presentation  of  the  breech,  of  the 
feet,  and  the  knees,  have  each  of  them  the  legs  in  precisely  the 
same  situation  when  delivered:  so  true  is  this,  that  did  we  not 
arrive  before  this  happened,  we  could  not  tell  with  which  of 
these  presentations  the  labour  commenced — the  same  may  be 
said  of  all  the  rest.  We  are,  therefore,  much  indebted  to  Baude- 
locque,  for  his  ingenious  and  natural  arrangement  of  these  labours. 
It  is  also  remarkable,  that  the  frequency  or  infrequency  of  each 
of  these  different  species  of  natural  labour,  should  be  with  few 
exceptions,  in  the  order  of  their  numerical  succession:  thus,  the 
first  presentations  of  the  breech,  feet,  and  knees,  are  more  fre- 
quent than  the  second;  the  second  more  frequent  than  the  third; 
and  this  third  more  frequent  than  the  fourth,  &c. 

916.  Why  is  it  that  we  meet  w^ith  more  presentations  of  the 
feet  in  premature  deliveries,  than  in  those  at  full  time?  or,  is  it 
only  coincidence? 

Sect.  II. — Preternatural  Labours  in  which  the  Child  pre- 
sents the  Feet. 

917.  The  causes  which  may  render  a  labour  preternatural,  in 
which  the  child  presents  the  feet,  may  be  any  of  those  already 
enumerated;  (G51)  or  it  may  depend  upon  some  irregular  and 
inefficient  action  of  the  uterus,  or  the  mere  position  of  the  child 
itself.  Should  either  of  these  accidental  causes,  complicate  a 
labour  in  which  the  child  presents  the  feet,  we  must  consider  it 
a  sufficient  reason  for  interfering  with  its  progress ;  and  we  must 


FIRST  AND  SECOND  PRESENTATIONS,  341 

expedite  the  delivery  by  bringing  down  the  feet;  the  mode,  how- 
ever, of  doing  this  will  depend  upon  the  particular  presentation 
we  may  have  to  contend  with. 

918.  From  the  position  which  the  feet  almost  always  assumes 
in  these  presentations,  it  will  be  readily  perceived,  that  one  can- 
not well  descend  without  the  other,  and  that  it  is  the  width  of 
the  breech,  thighs,  and  legs,  which  offer  together  at  the  superior 
strait;  hence,  they  will  sometimes  become  jammed,  at  this  part, 
and  the  feet,  or  a  foot,  will  cease  to  advance,  and  as  this  may 
happen,  and  the  difficulties  of  the  labour  arising  from  this  may 
be  increased,  by  some  one  of  the  accidents  already  enumerated 
(651)  they  give  sufficient  reason,  for  manual  interference.  Or 
the  uterus  may,  from  any  of  the  causes  we  have  already  ack- 
nowledged to  be  capable  of  such  effect,  be  incompetent  -to  force 
the  parts  down  to  the  bottom  of  the  pelvis,  though  no  embarrass- 
ment be  created  by  position.  Or  the  fourth  presentation  itself 
may  be  considered  as  essentially  bad,  and  require  our  interfer- 
ence. 

919.  Under  either  of  these  circumstances,  we  are  obliged  to 
convert  an  otherwise  natural,  into  a  preternatural  labour.  It  will 
be  constantly  kept  in  mind,  when  taking  hold  of  the  feet  is 
recommended,  it  is  always  supposed  that  the  membranes  have 
been  ruptured,  and  the  os  uteri  dilated,  as  has  been  uniformly 
been  inculcated  for  every  operation  of  the  kind.  It  may  be  re- 
marked here,  that  there  will  be  some  difference  in  the  mode  of 
acting  in  footling  cases,  arising  from  the  circumstance  of  presen- 
tation, or  of  one  or  both  feet  being  within  reach;  but  these  will 
be  illustrated  as  we  proceed.  We  will  repeat,  lest  it  be  forgot- 
ten, that  the  woman  is  supposed  to  bo  constantly  placed  upon  her 
back,  as  recommended  for  all  cases  of  preternatural  labours. 

Sect.  III. — Mode  of  acting  in  the  First  and  Second  Presen- 
tations of  the  Feet. 

920.  It  has  already  been  remarked,  that,  in  both  these  presenta- 
tions, when  the  feet  are  without  the  vulva,  that  the  mecha?iism,  is 
the  first  and  second  breech  presentations;  therefore  I  shall  only 
point  out  the  mode  of  treating  the  labour  until  that  period;  for, 
afterwards,  everything  must  be  conducted  as  directed  for  those 
presentations. 

921.  When  it  is  agreed  that  there  is  a  necessity  to  expedite 
the  labour,  it  must  be  done  by  introducing  the  hand  into  the  va- 


342  FIRST  AND  SECOND  PRESENTATIONS. 

gina,  if  the  feet  still  remain  at  the  superior  strait;  if  this  be  the 
case,  we  pass  the  hand  until  we  can  by  a  proper  grasp  possess 
ourselves  of  them:  and,  when  secured,  we  draw  them  downward; 
but,  if  this  require  more  force  than  it  would  be  prudent  to  exert, 
we  must  desist,  and  act  upon  the  breech,  by  gently  raising  it 
upwards,  this  will  almost  always  permit  the  feet  to  fall  down; 
or,  at  all  events,  enable  us  to  proceed  with  them  through  the 
pelvis.  Should  but  one  foot  ofier,  we  may  act  upon  it,  and  often- 
times successfully,  when  the  child  is  small  compared  with  the 
size  of  the  pelvis;  but  if  it  come  reluctantly,  and  evidently  re- 
quiring a  considerable  degree  of  force  to  bring  it  along,  we  should 
cease  to  act  upon  it,  and  search  for  the  other  foot. 

922.  When  the  second  foot  is  accessible,  it  is  always  best  to 
make  it  descend  with  the  first;  and  not  merely  push  it  up  that  it 
may  unfold  itself  along  the  abdomen  of  the  child.  But  let  it  be 
recollected,  when  we  are  obliged  to  search  for  the  second  foot,  it 
is  a  matter  of  consequence  to  make  a  proper  choice  of  hand;  for 
it  may  be  resting  on  the  margin  of  the  pelvis,  or  it  may  be  un- 
folded and  high  up  in  the  uterus;  therefore,  in  either  case,  the 
facility  of  the  operation  will  very  much  depend  upon  the  hand 
that  is  employed — this  I  well  know  from  experience.  The  rule 
in  these  cases  is  precisely  the  same  as  for  the  breech  cases  of  the 
same  numerical  denominations;  namely,  the  left  hand  for  the 
first,  and  the  right  hand  for  the  second  presentation,  &.c. 

923.  The  reasons  wherefore  I  prefer  having  both  feet  to  act 
upon  in  these  cases  are, — first,  we  can  exert  the  necessary  force 
to  much  greater  advantage  by  acting  with  both;  second,  we  run 
much  less  risk  of  doing  injury  to  the  limbs;  for  if  we  act  by  one 
alone,  we  may  chance  to  hurt  it  by  the  force  not  being  divided; 
third,  we  can  give  a  better  direction  to  the  body  as  it  descends; 
when  it  is  necessary  to  efiect  any  change  upon  its  course. 

924.  The  only  difference  in  the  mode  of  acting  in  the  second 
presentation  and  the  first,  is  the  necessary  choice  of  hand — in 
every  other  respect  the  mechanism  is  the  same. 

925.  Should  more  than  two  feet  be  found  in  the  passage,  as  in 
twin  cases,  we  must  be  careful  to  select  those  which  belong  to  the 
same  child;  this  sometimes  creates  more  difficulty  than  would  at 
first  be  imagined;  for  simply  selecting  a  right  and  left  foot,  by 
no  means  proves  they  belong  to  the  same  body;  and  if  they  should 
not,  much  inconvenience  may  be  experienced.  It  is  true,  this 
circumstance  will  rarely  occur,  as  it  seldom  happens  that  the 


THIRD  AND  FOURTH  PRESENTATIONS.  343 

membranes  of  both  give  way  at  the  same  time,  or  before  one  of 
the  children  is  delivered;  yet  it  happens  sufficiently  often  to 
make  the  caution  necessary.  An  instance  of  this  kind  occurred 
to  me  some  years  ago;  for  in  attempting  to  bring  down  two  feet, 
(properly  selected,  as  I  supposed.)  where  there  were  three,  I  got 
a  foot  of  each  of  the  children ;  I  discovered  my  mistake,  how- 
ever, sufficiently  early  to  enable  me  to  pass  up  my  hand,  and 
select  the  proper  foot,  but  not  without  some  difficulty. 

Sect.  IV. — Method  of  Acting  in  the  Third  and  Fourth  Pre- 
sentations of  the  Feet. 

926.  Were  I  permitted  to  draw  a  conclusion  from  my  own  ex- 
perience, or  take  for  fact  what  is  stated  in  the  register  of  "  I'Hos- 
pice  de  Maternite,"  cither  of  these  presentations  would  be  found 
to  be  extremely  rare,  and  especially  the  last.  Of  the  third  pre- 
sentation, I  find  but  three  instances  recorded  in  nearly  thirteen 
thousand  cases,  in  the  practice  of  that  institution,  and  of  the 
fourth  but  one.  In  examining  my  own  practice,  I  find  two  of 
the  third,  and  but  one  of  the  fourth  presentation. 

927.  The  third  presentation  is  not  so  replete  with  inconvenien- 
ces as  the  fourth,  nor  so  uniformly  fatal  to  the  child;  yet  they 
are  sufficiently  so,  to  make  us  fear  when  it  occurs,  especially,  if 
the  forehead  does  not  spontaneously  turn  from  the  projection  of 
the  sacrum,  and  place  itself  before  the  sacro-iliac  symphysis  of 
one  side  or  other  of  the  pelvis  that  the  head  may  descend  in  a 
diagonal  situation  to  the  lower  strait — when  it  arrives  at  this 
place,  and  in  this  direction,  it  will  rarely  happen  that  the  face 
cannot  be  made  to  apply  itself  to  the  perinseum  at  the  last  period  of 
labour. 

928.  Should  this  favourable  disposition  of  the  head,  however, 
not  take  place  spontaneously,  it  points  out  what  should  be  done 
to  make  the  labour  more  advantageous  to  both  mother  and  child. 
Should  we  have  charge  of  the  case  sufficiently  early,  that  is,  be- 
fore the  feet  have  descended,  and  when  the  membranes  have  but 
lately  yielded,  we  may  dispose  the  head  to  turn  to  one  side,  by 
making  the  body  observe  an  oblique  position  in  its  descent,  by 
turning  the  toes  to  one  side  of  the  pelvis.  Indeed,  this  would 
seem  to  be  almost  the  only  period  at  which  we  could  pretend, 
with  any  certainty  of  success,  to  do  this,  by  any  manoeuvre  per- 
formed on  the  body  of  the  child;  for  after  it  is  either  in  part,  or 
wholly  delivered,  they  would  be  almost  nugatory. 


344  THIRD  AND  FOURTH  PRESENTATIONS. 

929.  We  are  directed  by  most  writers  who  have  mentioned  this, 
and  the  fourth  presentation,  to  attempt  this  change,  by  giving  an 
extensive  twist  to  the  body.  Thus  La  Motte,  Levret,  and  Smel- 
lie,  advise  this  motion  to  be  made,  by  turning  the  child's  body, 
under  the  expectation  that  the  head  and  face  will  obey  the  im- 
pulse, without  seeming  to  recollect  that  in  these  cases  the  head  is 
not  very  movable  in  the  pelvic  cavity,  especially  when  the  waters 
have  been  long  drained  off;  and  that  to  change  it  would  require 
much  more  force  than  can  be  safely  exerted,  or  a  much  more 
extensive  twist  of  the  child's  neck  than  would  be  compatible 
with  its  safety. 

930.  When  the  body  is  delivered,  and  the  shoulders  have  de- 
scended sufficiently  low  to  permit  it,  we  should  immediately 
ascertain  whether  the  position  of  the  head  be  correct  or  not — 
should  its  position  be  favourable,  we  proceed  with  the  labour, 
as  had  been  already  directed  for  the  breech;  should  it  not,  we  must 
endeavour  to  rectify  it,  by  acting  upon  the  face  so  soon  as  the 
shoulders  have  been  cautiously  delivered;  that  is,  without  having 
exerted  a  force  upon  them,  sufficient  to  jam  the  head  in  a  bad 
direction  at  the  superior  strait. 

931.  Should  the  head  be  jammed  in  the  superior  strait,  by  any 
ill-directed  force,  it  must  be  relieved  as  quickly  as  possible,  if  we 
expect  to  preserve  the  child — this  must  be  done,  by  passing  the 
hand  under  the  head  at  the  bottom  of  the  pelvis,  and  gently  rais- 
ing it,  so  as  to  lift  the  vertex  from  behind  the  pubes,  and  at  the 
same  time  turn  the  face  to  one  side.  The  side  to  which  the 
face  must  be  turned,  will  depend,  first,  upon  the  inclination  it 
may  have  to  either  the  right  or  left  side;  choosing  that  always 
to  which  it  most  tends;  and,  second,  upon  the  hand  which  may 
be  employed  to  rectify  the  position,  when  no  inclination  toward 
one  side  or  the  other  is  observed ;  if  the  right  hand  be  used,  it 
will  be  easiest,  ceteris  paribus,  to  turn  it  towards  the  left,  and 
the  reverse. 

932.  Before,  however,  this  reduction  is  attempted,  it  will  be 
well  to  have  the  body  of  the  child  carefully  raised  by  an  assistant, 
towards  the  abdomen  of  the  mother,  that  the  hand  may  be  intro- 
duced with  more  certainty  and  facility;  care  being  taken  in  doing 
this,  that  the  head  is  not  drawn  down,  by  the  body  being  carried 
up.  When  the  position  of  the  head  is  adjusted,  we  must  act  as 
has  been  directed  in  such  cases  for  the  breech. 

933.  In  the  fourth  presentation,  we  can  scarcely  expect  to  im- 


THIRD  AND  FOURTH  PRESENTATIONS.  345 

prove  its  position,  unless  we  are  very  early  with  the  patient;  that 
is,  immediately  after  the  yielding  of  the  membranes,  and  liave,  at 
the  same  time,  the  os  uteri  sufficiently  dilated  to  enable  the  child 
to  obey  the  direction  we  mean  it  should  take.  Unless  we  can 
take  advantage  of  this  period  to  move  the  face  toward  one  of  the 
sides  of  the  pelvis,  I  am  disposed  to  believe  that  very  little  can 
be  done  until  the  shoulders  are  without — except  indeed  the  head 
be  small  compared  with  the  pelvis;  in  this  case,  there  is  very 
little  necessity  for  assistance,  as  it  will  pass,  face  upward,  under 
the  arch  of  the  pubes,  without  much  difficulty. 

934.  When  the  shoulders  are  without,  I  am  sure  it  will  some- 
times succeed,  to  turn  the  face  towards  one  of  the  foramina  ova- 
lia;  the  occiput  by  this  change,  will  descend  a  little,  and  offer  it- 
self towards  one  of  the  tubers  of  the  ischia,  or  a  little  obliquely 
as  regards  the  lower  strait;  and  may,  by  a  well-directed  force, 
aided  by  the  voluntary  contributions  of  the  mother,  be  made  to 
escape  in  this  diagonal  position. 

935.  I  would  always  recommend  to  the  young  practitioner, 
in  cases  of  such  very  doubtful  issue  to  the  child,  and  more 
especially,  in  the  fourth  presentation,  to  advertise  the  friends 
of  the  patient,  of  the  risk  the  child  must  inevitably  run  in  its 
delivery,  that  no  exorbitant  hopes  may  be  entertained  of  its 
eventual  safety. 

936.  There  will  be,  of  course,  the  same  propriety  in  using  the 
forceps  in  any  of  these  cases,  as  was  expressed  for  their  employ- 
ment in  breech  cases. 


44 


346 


CHAPTER  XXIX. 

PIIESENTATIONS  OP  THE  KNEES. 

937.  The  presentation  of  the  knees  are  very  rare  indeed;  and 
1  might  perhaps  have  passed  them  over  in  silence,  without  incur- 
ring much  censure  for  the  omission.  But  I  have  chosen  to  notice 
them,  because  they  are  rare;  and  because  they  are  sometimes  em- 
barrassing to  the  young  practitioner;  for  I  well  recollect  my  own 
trepidation,  when  called  to  a  case  of  this  kind  in  the  very  com- 
mencement of  my  practical  career.  To  add  to  my  embarrass- 
ment, I  was  called  to  the  assistance  of  a  midwife,  who  could  not 
well  have  been  more  ignorant  of  what  was  proper  to  be  done  than 
myself.  I  will  not  pretend  at  this  time  to  designate  the  particu- 
lar presentations  of  the  knees,  as  I  knew  nothing  about  their  pre- 
sentations at  that  time ;  I  only  recollect,  that  I  reasoned  in  the 
following  manner  upon  the  subject: — "If  the  feet  were  without, 
I  should  feel  little  or  no  difficulty  in  the  case,  as  1  once  attended 
a  labour  of  this  kind  successfully ;  and  it  cannot  be  very  danger- 
ous to  pass  the  hand  to  them,  since  they  must  be  in  the  neigh- 
bourhood of  the  knees."  With  these  reflections,  I  passed  a  hand 
into  the  vagina,  and  tracing  the  legs,  soon  obtained  the  feet,  which 
I  had  the  good  luck  to  bring  along,  by  accidentally,  (for  so  it 
was,  as  I  had  no  principles  to  direct  me,)  disengaging  the  knees 
from  the  margin  of  the  pelvis,  against  which  I  now  know  they 
must  have  butted,  and  terminated  the  labour  successfully  to  both 
mother  and  child,  but  with  severe  agony  to  myself. 

938.  These  presentations  are  more  unusual  than  any  I  have 
hitherto  considered  ;  not  occurring  oftener,  perhaps,  than  once  in 
a  thousand  or  more  times.  They  are  less  favourable  than  any  of 
the  presentations  I  have  classed  as  natural;  and  agreeably  to 
Baudelocque,  they  may  present  in  four  ways: 

939.  In  the  first  presentation  of  them,  the  legs  are  to  the  left 
side  of  the  mother,  and  the  thighs  to  the  right. 

940.  In  the  second,  the  legs  to  the  right,  and  the  thighs  to  the 
left. 

941.  In  the  third,  the  legs  under  the  arch  of  the  pubes,  and 
the  thigh  towards  the  sacrum. 


PRESENTATIONS  OP  THE  KNEES,  347 

942.  In  the  fourth,  we  find  a  reverse  of  the  third. 

943.  The  mechanism  of  these  labours  are  precisely  the  same 
as  those  of  the  feet;  for  the  latter  must  be  quickly  developed, 
if  the  labour  proceed;  and  then  they  are  reduced  to  footling 
cases. 

944.  The  knees  may  be  distinguished,  when  together,  by  their 
similarity,  and  the  roundness  of  the  bony  angles  they  form. 
When  but  one  presents,  which  is  most  commonly  the  case,  it  is 
not  so  easy;  but  we  may  trace  the  leg,  and  find  by  this  means 
the  foot,  which  puts  the  matter  out  of  doubt. 

Sect.  I. — Causes  which  may  render   Presentations  of  the 
Knees  preteymatural. 

945.  Until  the  membranes  be  ruptured,  and  the  uterus  pro- 
perly dilated,  a  presentation  of  the  knees,  if  the  presentation  can 
be  discovered  before  that  period,  is  to  be  treated  as  has  been  di- 
rected for  the  breech  or  the  feet. 

946.  Baudelocque  directs  that  we  should  not  search  for  the 
feet  in  these  presentations,  unless  the  labour  be  complicated  by 
some  accident;  but  the  difficulties  which  a  woman  almost  always 
experiences  in  delivering  herself  in  these  cases,  are  such  as  to 
render  it,  I  think,  the  better  practice  always  to  bring  down  the 
feet;  especially  in  the  earlier  part  of  the  labour,  when  neither 
force  is  required,  nor  inconvenience  hazarded,  b}'^  the  proceeding. 
I  once  witnessed  a  case,  where  many  hours  of  severe  suffering  had 
been  endured,  from  a  presentation  of  the  knees,  without  its  hav- 
ing made  the  smallest  progress,  after  the  first  hour  or  two:  the 
breech  and  knees  had  progressed  together  in  such  a  manner  as  to 
completely  occupy  the  pelvis;  several  pretty  severe  attempts  had 
been  made  by  the  midwife,  as  she  herself  declared,  to  make  the 
knees  descend,  by  acting  upon  them  to  the  serious  injury  of  the 
child.  After  this  period,  I  was  requested  to  visit  the  patient.  I 
found  the  presentation  to  be  the  first;  but  the  breech  had  de- 
scended so  much  as  to  carry  the  knees  against  the  right  sacro- 
iliac symphysis,  and  thus  prevented  the  farther  progress  of  the 
labour.  I  introduced  the  right  hand,  and  with  some  exertion 
was  enabled  to  raise  the  breech  sufficiently  to  permit  the  feet  to 
fall  down  near  fo  the  os  externum;  the  knees  were  then  readily 
removed  from  their  position,  and  the  delivery  speedily  effected. 

947.  Now,  as  there  is  no  security  that  the  breech  will  not  de- 
scend in  proportion  to  the  advancement  of  the  knees,  and  if  it 


348  PRESENTATIONS  OF  THE  KNEES. 

do,  the  knees  will  almost  certainly  be  arrested  against  some  por- 
tion of  the  pelvis,  in  which  case  the  contractions  of  the  uterus 
and  the  efforts  of  the  woman,  are  almost  sure  to  be  unavailing, 
though  continued  for  hours,  I  think  it  always  best  to  bring  down 
the  feet  and  knees,  by  pushing  up  the  breech,  whether  the  case 
be  free  from,  or  complicated  by  any  of  the  accidents  already  men- 
tioned ;  unless  the  os  uteri  is  sufficiently  dilated,  and  the  feet  are 
found  to  unfold,  or  the  knees  to  advance;  in  this  case  we  may 
trust  the  labour  to  nature. 

Sect.  II. — Mode  of  Operating  hi  Presentations  of  the  Knees. 

948.  When  we  attempt  the  relief  of  the  woman  in  such  cases, 
we  should  commence  as  early  as  the  state  of  the  uterus  will  per- 
mit, and  especially  when  it  may  be  either  the  third  or  fourth  po- 
sition; in  either  of  which  we  should  experience  all  the  inconve- 
niences which  are  found  in  the  third  and  fourth  presentations  of 
breech  and  feet,  with  the  contingency  of  the  knees  stopping  in 
their  progress;  and  this,  at  a  time  when  it  might  be  either  dif- 
ficult or  dangerous  to  attempt  making  the  changes  upon  the 
direction  of  the  body,  so  important  to  the  safe  delivery  of  the 
head. 

949.  Baudelocque  recommends  pushing  up  the  knees  when  we 
attempt  their  reduction ;  but,  so  far  as  I  am  capable  of  compar- 
ing the  two  methods,  I  think  acting  upon  the  breech  is  the  bet- 
ter plan. 

950.  He  also  advises  the  employment  of  the  fillet,  or  blunt 
hook,  for  the  delivery  of  the  knees — I  confess  I  have  tried  nei- 
ther— but  it  appears  to  me  they  cannot  in  every  position  of  the 
knees  be  employed  with  advantage;  but  in  one  I  think  they  may 
aid,  (that  is,  the  fourth,)  when  these  parts  have  descended  low  in 
the  pelvis ;  as  then  the  direction  necessary  to  the  delivering  them 
will  be  the  one,  and  the  only  one,  we  can  give  them  by  either 
fillet  or  blunt  hook.  The  proper  hand  must  be  employed,  when 
we  attempt  to  raise  the  breech,  or  we  may  fail  in  the  attempt 
to  liberate  the  feet  and  knees — in  the  first  presentation,  we  must 
use  the  right  hand ;  in  the  second,  the  left ;  and  in  the  third  and 
fourth,  either. 


349 


CHAPTER  XXX. 


OP  TEDIOUS   LABOUR, 


951.  Many  causes  have  been  assigned  for  tedious  labour;  some 
of  which,  are  sufficiently  evident;  while  others  are  extremely 
obscure,  if  not  altogether  inscrutable.  The  causes  have  been 
divided  into  constitutional  and  local;  both  of  which  unquestion- 
abl}^  may  exist;  but  the  former  is  much  more  rare  than  the  latter. 
The  general,  or  constitutional  causes,  appear  to  consist  almost 
exclusively  in  passions,  or  emotions  of  the  mind;  or  at  least,  to 
some  peculiar  condition  of  the  sensorium  commune,  and  nervous 
system.  Thus,  we  see  the  uterine  action  rendered  feeble  and 
transitory  for  many  hours  together,  or  suspended  from  half  an 
hour  to  a  number  of  days,  from  the  influence  of  some  unexpected 
or  distressing  intelligence;  or  sometimes,  even  the  presence  of  a 
strange  accoucheur  (259)  or  midwife,  will  have  the  same  effect. 

952.  The  state  of  the  muscular  system,  appears  to  have  but 
little  influence  upon  uterine  contraction;  for  when  it  exists  in  its 
most  healthy  condition  it  by  no  means  ensures  the  best  efforts 
of  the  uterus  ;  nor  does  a  state  of  almost  exhaustion,  necessarily 
interrupt  the  regular  and  successful  play  of  this  organ. 

953.  Nay,  we  may  go  farther  and  declare,  that  the  functions 
of  the  uterus  are,  in  very  many  instances,  never  more  rapidly, 
or'successfully  performed,  than  when  the  powers  of  the  muscular 
system  are  below  the  natural  standard  of  health,  or  even  indeed, 
when  they  are  much  reduced.  Thus,  in  the  last  stages  of  fever, 
or  of  phthisis  pulmonalis;  or  in  a  word,  any  other  exhausting 
disease,  the  uterus  at  the  proper  time,  is  almost  sure  to  discharge 
its  contents,  not  only  with  rapidity,  but  almost  without  pain. 
Here,  the  relaxed  condition  of  the  soft  parts  immediately  con- 
cerned in  the  act  of  delivery,  cease  to  oppose  the  contraction  of 
the  fundus  and  body  of  the  uterus;  and  this  organ  itself  seems  to 
be  so  economical  of  its  powers,  as  not  to  suffer  their  waste,  even 
when  all  the  other  muscles  of  the  body  are  rapidly  yielding  them. 
Here,  the  os  uteri  gives  way,  with  instant  and  seeming  willing- 
ness, to  uterine  contraction,  and  will  not  oppose  by  obstinacy  as 
in  most  cases,  the  passage  of  the  child,  and  render  labour  tedious. 


350  OF  THE  WANT  OF  CONTRACTILE  FORCE. 

954.  In  general,  the  condition  of  the  os  uteri,  (casteris  paribus) 
may  be  looked  upon  as  one  of  the  surest  guides  to  determine  the 
duration  of  labour;  and  hence,  when  it  is  not  disposed  to  yield, 
it  becomes  the  most  common  cause  of  tedious  labour;  and  hence, 
we  may  learn  why  the  local  cause  or  causes,  are  much  more  fre- 
quent in  their  operation  than  the  constitutional.  Among  these 
we  may  especially  reckon — 

1.  A  want  of  contractile  force  of  the  uterine  fibre.* 

2.  A  rigid  condition  of  the  soft  parts  concerned  in  labour;  es- 
pecially, the  mouth  of  the  uterus  itself. t 

3.  Cicatrices,  or  other  imperfections,  arising  from  injuries  done 
to  the  parts  concerned.  J 

4.  A  premature  escape  of  the  liquor  amnii. 

5.  Over-distention  of  the  uterus,  producing  torpor  or  inertia  of 
this  organ,  aad  too  dense  a  condition  of  the  membranes.  § 

Of  these  we  shall  treat  pretty  fully,  and  illustrate  the  opera- 
tions of  each  cause,  by  appropriate  examples. 

Sect.  I. — Of  the  tvant  of  Contractile  Force. 

955.  This  is  a  condition  of  the  uterus,  and  not  an  extremely 
unfrequent  one,  in  which  neither  of  the  other  enumerated  causes 
are  present,  and  for  which  it  would  be  very  difficult  to  assign 
the  true  one.  It  may,  however,  arise  from  some  original  defect 
of  the  uterine  fibre,  as  it  is  occasionally  found  to  be  habitual  with 
some  women ;  or  it  may  follow  the  over-action  of  this  organ.  In 
the  cases  under  consideration,  we  have  not  to  contend  with  any 
unfavourable  condition  of  the  soft  parts:  for  the  defect  seems  to 
be  seated  in  the  uterine  fibre  itself.  And  it  is  in  such  cases,  that 
the  ergot  or  secale  cornutum,  has  been  found  so  highly  useful. 
See  Chapter  on  Ergot. 

956.  I  shall  relate  a  few  cases,  by  way  of  illustration,  of  each 
of  the  conditions  of  the  uterus  just  named. 

a.  Where  the  powers  of  the  uterus  were  partly  exhausted  by 
long-continued  action. 

*  See  Chapter  on  Ergot. 

f  See  Section  on  Rigidity  as  a  cause  of  Tedious  Labour. 

+  See  Section  III. 

§  See  Sections  V.  and  VL 


OF  THE  WANT  OF  CONTRACTILE  FORCE.  351 


Case  First. 

1817,  Dec.  21st.  I  was  requested  to  visit  Mrs. ,  in  con- 
sultation. She  had  been  in  labour  sixteen  hours,  with  a  first 
child,  and  was  twenty-eight  years  of  age.  The  waters  had 
discharged  themselves  early  in  the  labour:  the  pains  had  been, 
up  to  a  certain  period,  strong  and  frequent;  the  head  had  passed 
the  OS  uteri,  and  every  expectation  was  entertained,  for  some 
time,  that  the  labour  would  have  terminated  promptly:  but  in 
this  the  medical  attendant,  and  the  friends  of  the  patient,  vvere 
disappointed. 

The  head  occupied  the  inferior  strait,  and  the  vertex  was  ap- 
plied nearly  fair  to  the  arch  of  the  pubes.  For  some  time  the 
pains  continued  to  be  frequent,  but  feeble;  but  eventually,  they 
nearly  subsided  altogether;  after  waiting,  with  things  in  this 
condition  for  six  hours,  without  the  smallest  advantage,  I  was 
requested  to  visit  the  patient. 

I  found  the  lady  sufiering  much  from  a  generally  spread 
pain  over  the  abdomen;  some  fever;  great  restlessness;  pains 
nearly  gone,  and  very  inefficient;  and  the  head  about  to  emerge 
from  under  the  pubes.  I  soon  perceived  that  the  uterine  forces 
were  totally  inadequate  to  depress  the  parietal  protuberances 
below  the  tubers  of  the  ischia.  We  however  waited  twenty 
minutes  more  to  ascertain  the  absolute  power  of  the  pains,  and 
during  each,  attempted  to  aid  it,  in  the  adaptation  of  the  vertex 
to  the  arch  of  the  pubes;  that  is,  I  assisted  to  turn  the  face  ex- 
actly into  the  hollow  of  the  sacrum.  By  this  change  in  the  po- 
sition of  the  head,  some  advantage  was  gained,  as  it  necessarily 
diminished  resistance;  but  it  did  not  enable  the  uterus  to  accom- 
plish the  labour.  By  this  time  the  patient  could  hardly  be  said 
to  have  pains. 

I  now  proposed  to  give  our  patient  twenty  grains  of  ergot: 
this  was  acceded  to,  and  it  was  administered  to  her  immediately. 
This  first  dose  of  the  ergot  evidently  roused  the  dormant  powers 
of  the  uterus;  and  a  second,  of  the  like  quantity,  enabled  it  to 
expel  a  very  large  healthy  child. 

Case  Second. 

1818,  May  30th.  1  was  called  at  eight  o'clock,  P.  M.  to  Mrs. 


352  OF  THE  WANT  OF  CONTRACTILE  FORCE. 

,  the  mother  of  several  children;  she  was  constitutionally  de- 
licate and  nervous.  Her  pains  were  weak,  and  returned  only  at 
long  intervals,  sometimes  not  recurring  oftener  than  once  an  hour. 
On  the  31st,  at  eight  o'clock,  A.  M.  I  made  an  examination  for 
the  first  time;  found  the  os  uteri  dilated  pretty  considerably,  and 
very  yielding;  pains  still  very  slow.  During  a  pain  I  gently 
stretched  the  mouth  of  the  uterus,  with  a  hope  it  might  excite  a 
stronger  action  in  the  body  and  fundus,  but  without  advantage. 
As  the  parts  were  all  favourably  disposed,  I  ruptured  the  mem- 
branes: this  also  failed  to  excite  contractions  of  a  better  quality. 
At  two  o'clock,  P.  M.  I  gave  twenty  grains  of  the  secale  cornu- 
tum,  and  repeated  it  in  fifteen  minutes:  pains  now  succeeded 
each  other  so  rapidly  and  forcibly  as  to  deliver  the  child  safely  in 
fifteen  minutes  more. 

No  case  can  better  decide  the  influence  and  specific  action  of 
the  secale  cornutum  than  the  one  just  related.  It  most  striking- 
ly exhibits  the  superiority  of  this  drug  over  the  rupturing  of  the 
membranes,  though  this  operation  is  one  which  often  succeeds. 
We  are  aware  that  the  practice  of  rupturing  the  membranes  is 
condemned  by  some,  under  almost  any  circumstance;  but,  in 
doing  this,  I  had  in  expectation,  first,  that  by  taking  off  the 
distending  cause  from  the  uterus,  it  would  assume  its  usual  pow- 
ers, as  not  unfrequently  happens  when  the  waters  are  removed, 
by  the  unequal  surface  presented  by  the  child,  proving  a  stimu- 
lus to  this  organ;  and,  secondly,  and  particularly,  that  the  tonic 
contraction  would  so  certainly  take  place,  as  to  secure  my  patient 
against  a  subsequent  hasmorrhage. 

b.  Where  a  want  of  power  in  the  longitudinal  fibres  of  the  ute- 
rus appeared  to  be  the  cause  of  the  delay  of  delivery. 

Case  Third. 

1819,  May  26th.  I  was  called  to  Mrs. ,  in  labour  with  her 

sixth  child.  She  was  attacked  with  pain  twenty-four  hours  be- 
fore; they  had  augmented  gradually,  but  were  very  irregular  in 
their  recurrence,  though  very  severe.  The  os  uteri  was  found 
pretty  fully  dilated;  the  head  of  the  child  was  at  the  superior 
strait,  and  resting  upon  the  pubes,  in  consequence  of  a  pretty  ex- 
tensive anterior  obliquity  of  the  uterus.  Things  continued  in  this 
posture  until  two  o'clock,  P.  M.  of  the  27th.  I  now  ruptured  the 
membranes  hoping  it  might  increase  the  contractions  of  the  ute- 


RIGIDITY,  &C.  OF  THE  SOFT  PARTS.  353 

rus,  or  give  them  more  efficacy;  for  though  the  pains  were  very 
severe  as  regards  sensation,  they  manifested  very  little  propulsive 
power. 

The  rupturing  of  the  membranes  was  not  followed  by  the  slight- 
est advantage;  I  therefore  determined  on  giving  the  ergot;  a 
scruple  dose  was  accordingly  given.  It  may  be  proper  to  remark, 
that,  up  to  this  moment,  the  head  had  not  advanced  a  line.  In 
fifteen  minutes  after  the  ergot  was  given,  the  pains  became  pow- 
erfully propulsive;  and  in  a  quarter  of  an  hour  more,  my  patient 
was  safely  delivered  of  a  fine  healthy  boy. 

957.  This  case,  like  many  others,  decidedly  shows  the  influence 
of  ergot  upon  the  uterus;  but  perhaps  it  declares,  in  an  especial 
manner,  its  power  over  the  action  of  the  longitudinal  fibres  of  this 
viscus;  which,  as  I  have  already  observed,  (508)  have  the  greater 
agency  in  expelling  the  child.  My  reasons  for  thinking  so  are, 
first,  because  there  were  pains,  even  violent  ones,  from  the  com- 
mencement of  the  labour,  until  the  very  period  of  exhibiting  the 
ergot,  without  the  child  being  forwarded  by  them  in  the  slightest 
degree;  second,  because  the  rupturing  of  the  membranes,  a  plan 
generally  successful  in  increasing  pain,  failed ;  third,  because  the 
labour  was  terminated  very  soon  after  the  character  of  the  pains 
was  changed,  by  the  exhibition  of  the  ergot — or,  in  other  words, 
by  the  longitudinal  fibres  being  stimulated  to  a  healthy  and  effec- 
tive action. 

Sect.  II. — Of  Rigidity,  S,^c.  of  the  Soft  Parts,  as  a  cause  of 
Tedious  and  Preternatii^ral  Labour. 

958.  Writers  upon  midwifery  have  but  y^xy  imperfectly  con- 
sidered the  rigidity  of  the  soft  parts  as  a  cause  of  difficult  or  tedi- 
ous labour — some  indeed  do  not  mention  it,  and  others  do  so, 
merely  en  passant,  without  proposing  any  specific  treatment  for 
its  relief.  It  is  so  common  a  case,  that  every  practitioner  must 
have  met  with  it;  yet  it  has  failed  to  make  a  proper  impression, 
because  time  and  severe  suffering  have  eventually  overcome  it, 
though  not  always  with  safety  to  either  mother  or  child. 

959.  A  rigid  condition  of  the  soft  parts  may,  with  much  pro- 
priety, be  considered  the  most  frequent  of  the  causes  of  a  tedious 
labour;  especially  as  every  woman  may  be  subject  to  it,  as  well 
as  every  variety  of  presentation,  be  complicated  with  it.  It  may, 
perhaps,  be  difficult  to  define  by  words,  the  precise  condition  of 

45 


354  KIGIDITY,  &C.  OF  THE  SOFT  PARTS. 

parts,  said  to  be  rigid.  But  by  tbis  term  we  would  wish  to  con- 
vey the  idea,  that  certain  of  the  soft  parts  concerned  in  labour, 
as  the  OS  uteri,  peringeum,  &c.  offer  an  unusual  resistance  to  the 
efforts  which  the  fundus  and  body  of  the  uterus  make  to  expel 
their  contents;  and  it  is  in  this  sense  only,  we  employ  this  term 
in  this  place. 

960.  From  this  explanation,  it  seems  to  follow,  that  such  a  con- 
dition of  the  mouth  of  the  uterus  and  the  external  parts  may  ex- 
ist, as  will  resist  for  a  longer  time  than  natural,  (all  other  things 
being  equal,)  the  expulsive  efforts  of  the  fundus  and  body  of  this 
organ;  so  we  presume,  that  in  these  very  cases,  had  no  such  re- 
sistance from  the  parts  been  present,  that  a  lesser  degree  of  force, 
and  a  shorter  continuance  of  contractions,  would  have  effected 
the  delivery. 

961.  The  condition  of  the  soft  parts  under  consideration  arises 
perhaps,  in  a  failure  of  reciprocity  of  sympathy  in  the  several 
parts  concerned  in  labour.  For  in  fault  of  this  good  understand- 
ing, if  we  may  so  term  it,  the  ordinary,  and  essential  changes  for 
an  easy  delivery  do  not  take  place;  or  in  other  words,  to  employ 
the  language  of  Mr.  Hunter,  the  stimulus  of  relaxation  is  not 
given,  or  is  not  obeyed.  This  want  of  consent,  however,  does 
not  necessarily  imply  a  morbid  condition  of  the  parts  concerned; 
though  it  must  in  many  instances,  have  such  an  origin.  Thus 
there  may  be  no  morbid  condition  of  the  os  uteri,  though  it  re- 
sists for  a  longer  time  than  usual  the  efforts  of  the  fundus  and  body, 

■  when  these  parts  have  been  prematurely  excited  to  action;  for  in 
this  case,  all  the  terms  of  utero-gestation  have  not  been  complied 
with.  While  on  the  other  hand,  when  the  uterine  developement 
is  perfect,  and  the  soft  parts  resist  the  efforts  of  the  body  and  fun- 
dus for  an  unnatural  period,  the  presumption  is,  that  some  mor- 
bid cause  may  be  operating,  so  as  to  change  the  nature  of  the 
sympathies  by  which  these  parts  are  governed  at  such  times. 

962.  For,  in  the  ordinary  course  of  a  healthy  labour,  the  mouth 
of  the  uterus  opens  by  some  secret  agency;  or  at  least  without 
any  apparent  force;  and  when  this  takes  place,  the  efforts  of  the 
body  and  fundus,  are  rendered  as  effective  as  prompt,  in  termi- 
nating the  labour;  but  when  this  does  not  happen  in  the  order 
just  stated,  the  os  uteri,  (all  things  being  otherwise  equal,)  is  then 
said,  in  popular  language,  to  be  rigid. 

963.  In  labours  of  the  latter  kind,  there  is  an  unnatural  resist- 
ance to  be  overcome;  and  to  effect  this,  unfortunately,  mechani- 


RIGIDITY,  &C.  OF  THE  SOFT  PARTS.  355 

cal  and  other  equally  improper  means  are  resorted  to;  which  so 
far  from  fulfilling  the  intention  in  view,  oftentimes  increases  the 
evil,  and  converts  an  otherways  safe  labour,  (were  it  properly 
managed,)  into  one  of  great  danger;  or  at  least,  into  one  of  great 
tediousness,  and  difficulty.  In  such  cases,  and  with  such  conse- 
quences, it  is  at  once  evident,  that  a  wrong  principle  governs  the 
attendant;  for  he  attempts  to  overcome  the  resistance,  by  increas- 
ing the  force  of  the  body  and  fundus;  or,  by  forcing  open  the 
resisting  os  uteri  by  mechanical  means. 

964.  The  first  he  attempts,  by  the  exhibition  of  stimuli  of  one 
kind  or  other,  until  the  system  is  urged  to  the  formation  of  fever; 
or  to  fulfil  the  other,  he  stretches  the  mouth  of  the  uterus  so  rude- 
ly, or  so  repeatedly,  as  to  produce  in  it  an  incipient,  or  perhaps  a 
very  active  inflammation.  By  such  means,  he  defeats  the  opera- 
tions of  nature,  which  would  have  been  most  safely  performed,  if 
they  had,  by  a  well-regulated  plan,  been  permitted  so  to  do.  For, 
restofbody;  tranquillity  of  mind;  the  abstraction  of  stimuli;  the 
loss  of  blood;  free  bowels;  and  not  allowing  the  soft  parts  to  be 
disturbed,  by  ill-timed  and  officious  touching,  or  ill-conceived  ma- 
nual aid  at  the  mouth  of  the  uterus,  have  in  a  thousand  instances, 
overcome  every  difficulty  presented  by  simple  rigidity. 

965.  Many  of  the  errors  committed  in  the  treatment  of  the 
cases  of  tedious  labour  from  rigidity,  have  arisen  from  the  popular 
belief,  that  the  dilatation  of  the  os  uteri  is  effected  by  the  mechani- 
cal agency  of  the  child,  and  the  distended  membranes;  and  conse- 
quently, that  this  part  is  in  a  degree  subject  to  the  laws  which 
govern  impelled  bodies.  Two  very  important  mistakes  arise 
from  this  view  of  the  subject;  first,  it  prescribes  a  definite  time 
for  the  dilatation  of  the  os  uteri;  for  it  seems  to  be  assumed,  that 
the  contractions  of  the  body  and  fundus,  must,  in  a  given  time, 
force  open  this  part,  by  the  repeated  shocks  it  receives,  from  the 

foetus  being  urged  so  often  against  it. 

966.  Hence  we  find  Mr.  Burns  declaring  "  if  the  labour  be  go- 
ing on  all  the  time  but  slowly,  it  is  a  good  general  rule  to  effect 
the  dilatation  of  the  os  uteri  within  ten  or  twelve  hours  at  farthest 
from  the  commencement  of  regular  labour."  This  position  is  fol- 
lowed by  the  necessary  directions  for  the  fulfilment  of  this  inten. 
tion  by  mechanical  means;  and  though  we  acknowledge  the  mode 
pointed  out  for  this  purpose,  and  the  conditions  necessary  to  ren- 
der them  profitable,  are  as  well  guarded  as  the  assumption  of  the 
principle  will  permit,  yet  we  must  declare  our  unfeigned  aversioB 


356  RIGIPITV,  &C.   OF  THE  SOFT  PARTS. 

to  the  practice;  for  we  are  every  way  certain  that  it  can  be  done 
with  advantage  in  but  very  few  instances,  even  by  the  skilful ; 
and  never,  without  the  risk  of  much  mischief,  by  the  unskilful  or 
inexperienced  practitioner. 

967.  When  the  os  uteri  remains  unyielding  for  a  long  time,  it 
is  an  evidence  that  the  natural  processes,  which  so  beautifully, 
kindly,  and  safely  effect  this  change,  have  from  some  cause  or 
other  been  interrupted.  And  though  mechanical  force  may  be 
made  to  usurp  the  organic  function,  it  nevertheless  will  always  be 
at  the  expense  of  the  health,  or  even  the  integrity,  (be  this  more 
or  less,)  of  that  portion  of  the  uterus  to  which  force  is  applied. 

968.  So  well  assured  am  I  of  this  fact,  that  I  never  employ  force 
to  open  the  os  uteri.  Nor  do  I  hold  the  argument,  "that  no  mis- 
chief has  been  seen  to  follow  this  plan,"  of  the  slightest  weight; 
as  we  have  it  not  in  our  power  at  the  moment,  to  determine  satis- 
factorily, any  consequence,  but  the  proximate,  or  immediate  effect 
of  the  violence;  which  may  be,  and  most  probably  is,  but  slight, 
or  even  unappreciable  at  the  instant  it  is  committed.  But  can  we 
with  any  certainty  declare,  that  many  of  the  severe  and  danger- 
ous chronic  affections  of  the  neck  of  the  uterus,  do  not  owe  their 
origin  to  this  cause? 

969.  There  are  but  three  situations  of  the  os  uteri  with  which 
we  should  ever  interfere;  namely,  first.  When  this  part  does  not 
coincide  with  the  direction  of  the  uterine  forces,  and  the  axis  of 
the  vagina.  In  this  case,  labour  may  become  very  tedious,  for 
the  want  of  a  correspondence  of  axes;  I  therefore  attempt  to  es- 
tablish them,  as  directed  in  cases  of  obliquity  of  the  uterus.  See 
section  on  the  Obliquities  of  the  Uterus,  p.  115. 

970.  But  I  never  attempt  even  the  slight  change  here  spoken 
of,  until  the  os  uteri  is  yielding,  and  at  the  same  time  dilated,  to 
the  size  of  a  dollar,  and  the  pains  in  pretty  full  force.  By  this 
method,  not  the  slightest  violence  is  committed  ;  nor  is  even  pain 
excited. 

971.  Second.  When  the  pains  are  powerfully  protrusive,  and 
the  OS  uteri,  though  pretty  amply  dilated,  yet  not  sufficiently  so 
to  permit  the  parietal  protuberances  to  pass  freely  through  it.  In 
this  case,  much  time  and  suffering  are  very  often  saved,  by  run- 
ning the  extremity  of  the  finger  round  the  margin  of  the  os  uteri, 
and  gently  stretching  it.  For  in  many  instances,  if  we  gain  an 
increase  of  half  an  inch  in  the  diameter  of  this  part,  it  is  all  that 
is  required,  to  enable  the  head  to  pass  it. 


RIGIDITY,  &C,   OF  THE  SOFT  TARTS.  357 

972.  Third.  When  the  head  is  detained  by  the  anterior  portion 
of  the  uterus  being  in  advance  of  it,  and  holding  it,  as  it  were, 
in  a  sling.  In  this  case,  that  portion  of  the  neck  of  the  uterus, 
which  is  placed  before  the  head,  is  obliged  to  sustain  the  whole 
force  of  the  uterine  efforts;  in  consequence  of  which  it  becomes 
not  only  severely  stretched,  but  it  very  effectually  op])oses  the 
advancement  of  the  presenting  part,  and  gives  rise  to  much  un- 
necessary delay,  as  well  as  very  much  augmenting  the  sufferings 
of  the  patient. 

973.  This  case  is  one  of  very  frequent  occurrence:  and  women 
who  have  ample  pelves,  and  especially  those  who  have  had  several 
children,  and  are  liable  to  the  anterior  obliquity  of  the  uterus, 
are  more  particularly  obnoxious  to  it.  I  do  not  know  that  any 
writer  has  noticed  this  cause  of  tedious  labour;  and  though  this 
cannot,  strictly  speaking,  be  considered  as  an  instance  ofrigidjty, 
it  nevertheless  has  all  the  effects  of  that  condition,  as  it  creates 
delay,  by  a  portion  of  one  of  the  soft  parts  opposing  the  passage 
of  the  head;  and  may,  therefore,  with  much  propriety,  be  consi- 
dered under  the  present  head  of  our  subject. 

974.  We  are  every  way  satisfied  from  long  observation,  that 
this  situation  of  the  uterus,  and  of  the  head  of  the  child,  is  one  of 
the  most  common  causes  of  delay  when  everything  else  is  fa- 
vourably disposed,  that  occurs  in  practice;  at  least  in  this  coun- 
try. Whether  this  be  so  in  Europe,  where  the  remote  causes, 
namely,  large  pelves,  are  not  so  general,  we  are  unprepared  to 
say;  but  we  are  certain,  that  the  frequency  of  this  relation  of  the 
head  of  the  child,  and  the  anterior  portion  of  the  uterus  in  this 
country,  renders  such  labours  more  tedious  by  hours,  than  they 
would  be,  if  no  such  interposition  of  the  neck  of  the  uterus  took 
place. 

975.  It  is  true,  that  the  remora  which  the  neck  of  the  uterus 
offers  to  the  passage  of  the  head  when  down  before  it,  never  of 
itself  creates  a  serious  difficulty;  the  evil  chiefly  consists  in  a 
painful  and  an  unnecessary  delay;  but  as  the  case  is  always 
manageable,  when  it  is  proper  to  offer  aid,  it  is  certainly  right 
to  correct  this  deviation  from  a  strictly  healthy  labour,  as  early 
as  circumstances  will  permit. 

976.  The  proper  time  to  act  is,  when  the  hand  occupies  the 
inferior  strait  and  vagina,  completely;  when  the  pains  are  active; 
and  when  the  os  uteri  is  sufficiently  dilated  to  permit  the  head  to 


358  RIGIDITY,  &C.   OF  THE  SOFT  PARTS. 

pass,  if  the  axis  of  the  head,  and  that  of  the  os  uteri,  were  coin- 
cident. 

977.  To  relieve  the  head  from  this  state  of  embarrassment,  we 
must  draw  the  prolapsed  edge  of  the  os  uteri  by  the  point  of  the 
finger  in  the  absence  of  pain,  towards  the  symphysis  pubis,  and 
maintain  it  there,  until  a  pain  comes  on.  At  this  moment,  the 
point  of  the  finger  is  to  be  placed  against  the  edge  of  the  uterus, 
which  is  to  be  pushed  upwards  between  the  head  of  the  child  and 
the  pubes.  Should  we  be  able  to  carry  the  prolapsed  portion  of 
the  uterus  above  the  advancing  portion  of  the  head,  the  former 
will  suddenly  withdraw  itself  from  the  finger;  the  vertex  will 
apply  itself  to  the  arch  of  the  pubes,  aud  the  labour  terminate  al- 
most immediately. 

97.8.  It  sometimes,  however,  requires  several  trials  of  this  kind 
before  they  may  succeed:  but  the  attempt  must  not  be  abandoned 
because  it  fail  a  few  times:  for  the  principle  is  a  correct  one; 
and  should  be  acted  upon  perseveringly,  should  perseverance 
be  necessary.  We  have  everything  to  gain,  if  we  succeed:  and 
nothing  to  lose,  if  it  fail;  a  disappointment,  by  the  by,  which  can- 
not well  happen,  if  the  process  for  the  restoration  of  the  prolapsed 
part  be  properly  condu^.ted. 

979.  We  are  convinced  that  we  have  seen  very  many  labours, 
shortened  by  hours,  by  acting,  as  just  proposed,  for  such  cases. 
It  would  be  extremely  difficult  to  determine,  a  priori,  the  dura- 
tion of  a  labour  of  this  kind,  if  left  to  itself;  as  the  resistance 
which  the  margin  of  the  uterus  offers  to  the  head,  will  for  a  long 
time  be  more  than  equal  to  the  power  of  the  uterine  forces ;  con- 
sequently, the  labour  becomes  stationary,  and  will  continue  to  be 
so,  until  the  margin  of  the  uterus  is  obliged  to  yield,  by  its  losing 
a  part  of  its  power  from  attenuation,  or  perhaps  by  tearing, 

980.  Nobody  estimates  the  general  rule,  "to  let  a  labour  alone 
that  is  advancing  well,  and  is  natural  in  its  general  relations," 
more  highly  than  we  do — we  look  upon  it  as  a  most  wholesome 
restraint  when  acted  upon;  and  is  everyway  calculated  to  dimi- 
nish ignorant  and  mischievous  officiousness.  But  this  rule,  like 
every  other  general  rule,  has  its  exceptions;  and  we  may  be  even 
accused  of  violating  it  unnecessarily,  when  we  make  the  cases 
under  consideration  exceptions;  but  we  should  feel  but  little  con- 
cern upon  this  head,  if  the  charge  be  even  preferred  against  us 
as  we  are  certain  that  we  are  justified  in  making  them,  from  an 
ample  experience. 


RIGIDITY,  &C.   OF  THE  SOFT  PAUTS.  359 

981.  Many,  nay,  perhaps  everybody,  (for  we  have  said  that 
we  did  not  know  that  this  case  had  been  noticed,)  will  condemn 
what  we  have  said  upon  this  subject,  and  consider  our  directions 
as  unnecessary,  if  not  mischievous,  because  they  have  never  had 
recourse  to  them,  but  have  permitted  the  uterus  to  perform  this 
duty  unaided;  therefore  they  say  nature  is  competent  to  the  work, 
and  when  she  is  competent,  she  is  not  to  be  interfered  with. 
Were  this  rule  rigidly  acted  up  to,  there  would  be  an  end  to  im- 
provement, not  only  in  the  obstetric  art,  but  in  the  whole  range 
of  practical  medicine.  Our  experience,  however,  teaches  us  not 
to  heed  this  sweeping,  indiscriminate  rule;  for  it  is  not  sound 
practice  to  permit  nature  to  struggle  through  difficulties  merely 
because  it  is  supposed  she  can  struggle  through  them;  and  to 
leave  it  for  some  time  a  moot  point,  whether  or  not  the  case 
will  eventuate  in  safety,  when  aid,  as  certain,  as  safe,  is  always 
at  command.  Nor  does  this  application  of  the  finger  ever  pro- 
duce pain  or  other  inconvenience,  if  properly  and  gently  ma- 
naged. 

982.  Besides,  much  delay  is  sometimes  experienced  from  this 
dropping  down  of  the  anterior  portion  of  the  uterus,  by  inter- 
rupting the  pivot-like  motion  of  the  head,  (627,)  from  completing 
itself ;  especially,  when  the  head  occupies  pretty  strictly  the  in- 
ferior strait.  In  this  case  the  posterior  fontanelle  will  remain  for 
a  long  time  stationary  behind  one  of  the  foramina  ovalia;  for  its 
advancement  towards  the  arch  of  the  pubes  is  prevented  by  the 
prolapsed  portion  of  the  uterus  interfering  with  the  motion  just 
mentioned,  by  embracing  too  strictly  the  advancing  part  of  the 
head. 

983.  But  the  pivot-like  motion  of  the  head  is  almost  always 
restored  the  instant  we  succeed  in  passing  the  depending  portion 
of  the  uterus  above  the  head  of  the  child  by  the  point  of  the  fin- 
ger, as  directed  above. 

984.  The  several  situations  of  the  os  uteri  just  described,  are 
the  only  ones  I  ever  interfere  with.  For  should  it  be  thick  and 
rigid,  though  pretty  well  opened,  I  never  have  recourse  to  me- 
chanical means  for  its  farther  enlargement ;  I  depend  upon  more 
time,  or  upon  the  therapeutical  means  to  be  named  presently. 

985.  But  let  us  now  consider  the  rigidity  of  the  os  uteri,  as  a 
cause  of  tedious  labour  ;  we  will  treat  of  its  several  varieties,  i4;s 
consequences,  and  mode  of  treatment. 


360  SPECIES  OF  RIGIDITY. 

Of  the  Species  of  Rigidity  of  the  Os  Uteri. 

986.  First,  it  may  arise  in  the  mouth  or  neck  of  the  uterus, 
from  the  circular  fibres  of  these  parts  maintaining  their  power  in- 
ordinately long;  but  not  inflamed. 

987.  Second,  this  condition  may  be  attended  with  inflamma- 
tion. 

988.  Third,  it  may  arise  from  previous  injury  done  the  parts, 
either  by  mechanical  violence,  or  inflammation,  and  its  conse- 
quences. 

989.  Fourth,  it  may  happen  from  a  relative  cause;'  as  the 
disproportionate  powers  between  the  longitudinal  and  circular 
fibres. 

990.  Fifth,  it  may  proceed  from  the  too  powerful  exercise  of 
the  tonic  contraction  of  the  uterus,  especially  of  the  fundus  and 
body. 

Rigidity  of  the  First  Kind. 

991.  This  species  may  be  divided  into  three  varieties;  viz.  1st, 
when  the  subject  is  very  young;  2d,  where  she  is  advanced  be- 
yond the  twenty -fifth  year;  and,  3d,  where  the  uterus  is  prema- 
turely excited  into  action. 

Vai\   1. 

992.  In  this  variety  the  soft  parts  are  found  to  yield  very  of- 
ten with  great  reluctance;  and  thus  making  this  labour  extremely 
tedious  and  painful;  it  would  seem  to  arise  from  the  incomplete 
developement  of  the  uterus — but  each  of  the  species  and  varieties 
will  be  best  explained,  by  apj)ropriate  cases. 

Case  First. 

"  Miss  V.  aged  fourteen  years  and  a  half,  was  taken  in  labour 
January  14,  1790.  She  had  been  in  pain  thirty-six  hours,  before 
I  saw  her;  that  is,  she  complained  for  that  period,  though  the 
pains  were  not  very  severe;  about  twelve  hours  before  I  visited 
her,  the  waters  were  discharged;  the  mouth  of  the  uterus  was 
but  very  little  opened,  and  the  external  parts  not  favourably  dis- 
posed; the  pains  were  now  very  severe,  and  the  head  was  press- 
ed pretty  deep  into  the  pelvis:  she  was  extremely  costive,  and 


SPECIES  OF  KIGIDITY.  361 

had  passed  no  urine  for  many  hours;  an  injection  was  ordered, 
which  operated  very  freely;  the  catheter  was  introduced,  and 
nearly  a  quart  of  water  was  drawn  off — she  was  much  relieved 
by  these  discharges.  An  hour  was  given,  in  hope  that  a  favour- 
able change  might  take  place  in  her  labour.  There  was  but 
very  little  heat  in  the  vagina,  for  she  had  been  rarely  touched. 
She  had,  however,  by  the  advice  of  her  midwife,  been  placed 
over  water,  and  fumigated  with  burning  onion-shells,  but  to  no 
purpose. 

I  now  bled  her  fifteen  ounces;  this  produced  some  little  change 
in  the  mouth  of  the  uterus,  but  not  sufficient  to  permit  the  head 
to  pass,  as  it  contracted  and  stiffened  with  each  pain.  In  an  hour 
more  she  was  again  bled  fifteen  ounces;  this  produced  sickness  of 
stomach,  which  was  my  signal  for  stopping.  Upon  examination 
now,  the  parts  were  found  sufficiently  dilated;  there  was  a  tem- 
porary suspension  of  the  pains,  but  ihey  soon  returned,  and  were 
of  competent  force,  and  much  more  tolerable — the  labour  was 
soon  after  terminated. 

Var.  2. — Or  ivhere  the  Subject  is  not  young,  but  with  her' first 
Child. 

993.  The  same  general  phenomena  present  themselves  in  this 
variety  as  in  the  first,  but  this  case  is  generally  rather  more  ob- 
stinate. 

Case  Second. 

1798,  February  17th,  Mrs. ,  aged  forty,  in  labour  with  her 

first  child;  she  had  been  long  in  labour  previously  to  my  seeing 
her,  and  had  suflered  much — her  pains  were  in  quick  succession; 
the  waters  were  still  undischarged;  the  uterus  opened  to  about 
the  size  of  a  quarter  dollar;  its  edges  very  firm;  no  disposition  in 
the  external  parts  to  relax — she  was  bled  largely,  (40  ounces)  and 
was  delivered  in  half  an  hour  after. 

Var.  3. — Or  luhere  the  Uterus  is  prematurely  called  into  Ac- 
tion. 

994.  This  may  happen  at  any  period  of  gestation,  or  in  any 
subject;  but  I  am  only  now  considering  those  cases  where  this 
takes  place  at  the  last  period.     It  would  in  this  variety  be  highly 

46 


362  SPECIES  OF  UIGIDITY. 

useful  to  distinguish  it  from  the  two  just  mentioned;  as  in  the  be- 
ginning it  requires  very  different  treatment.  .The  following  marks 
may  serve  to  detect  it:  1st.  The  unexpended  portion  of  the  neck 
of  the  uterus  may  sometimes  be  perceived  by  the  touch,  as  at  the 
eighth  month  or  a  little  after;  2d,  the  os  uteri  is  rigid,  during, 
and  in  the  absence  of  pain ;  3d,  the  pains  are  more  irregular  in 
their  accessions  and  in  their  continuance ;  4th,  no  secretion  of 
mucus,  nor  disposition  in  the  perinseum  to  relax ;  5th,  no  subsi- 
ding of  the  abdominal  tumour;  and  the  knowledge  of  some  violent 
mental  excitement,  or  muscular  exertion  having  preceded  the 
onset  of  pain. 

995.  Should  these  pains  however  be  suffered  to  proceed  with- 
out interruption,  it  will  eventuate  in  a  painful  and  tedious  labour 
— it  therefore  should  be  our  first  care  to  appease  uterine  contrac- 
tion, by  remedies  suited  to  the  condition  of  the  patient — blood- 
letting should  be  premised,  if  the  pulse  merely  j3er7nit  it,  and 
without  declaring  its  absolute  necessity;  especially,  as  the  case 
may  require  repeated  and  large  doses,  sometimes,  of  laudanum. 
Rest  should  be  strictly  enjoined ;  the  bowels  should  be  opened  by 
mild  laxatives,  if  costive;  this  should  be  followed  by  injections  of 
laudanum  and  water,  pro  re  nata — the  diet  should  be  mild,  and  in 
small  quantities.  By  this  kind  of  treatment  we  may  very  often 
have  it  in  our  power  to  interrupt  this  disagreeable  anticipation  of 
labour,  as  the  following  case,  among  many  others,  shows. 

Case  Third. 

1790,  January  29th,  Mrs.  M.  L. ,  aged  twenty,  pregnant 

of  her  first  child,  after  standing  all  day  at  the  ironing-table,  was 
seized  with  pretty  regular  pains.  There  was  no  subsiding  of  the 
abdominal  tumour;  no  secretion  of  mucus;  the  os  tincae  not  en- 
tirely obliterated.  There  was  very  little  tension  of  the  membranes 
during  a  pain;  from  these  circumstances  I  was  disposed  to  believe 
the  uterus  had  been  prematurely  excited  to  action.  She  was  or- 
dered to  lose  twelve  ounces  of  blood;  to  keep  quiet,  and  receive 
an  enema  of  a  gill  of  water,  and  a  tea-spoonful  of  laudanum — paip 
soon  subsided;  she  went  a  fortnight  longer,  and  her  labour  prb- 
ceeded  kindly,  and  was  not  of  long  duration. 

996.  In  cases  similar  to  the  above,  much  mismanagement  fre- 
quently takes  place;  especially,  when  the  patient  is  under  the 
care  of  an  ignorant  midwife,  who  supposes  the  attending  pains 


SPECIES  OF  RIGIDITY.  3G3 

can  only  proceed  from  a  commenced  labour:  particularly,  if  the 
reckoning  of  the  patient  be  nearly  expired;  she  is  of  course  fre- 
quently and  oftentimes  rudely  handled ;  the  uterus  irritated,  and 
the  whole  system  stimulated  by  improper  drinks  or  remedies, 
with  a  view  to  hasten  the  labour  as  it  is  called — the  following 
case  is  in  point. 

Case  Fourth. 

1790,  August  11th,  Mrs.  C.  pregnant  with  her  third  child, 
aged  twenty-eight,  after  a  severe  fright,  was  attacked  with  pains; 
as  her  midwife  was  engaged  at  the  time  she  was  sent  for,  I  was 
called  on.  From  her  being  disappointed  in  her  midwife  she  be- 
came very  much  alarmed,  and  her  pains  ceased  for  six  hours.  At 
the  expiration  of  this  period  they  returned,  and  the  midwife  ar- 
rived soon  after;  she  examined  her  and  found  nothing  like  labour. 
She  gave  her  a  large  dose  of  laudanum,  which  not  easing  her, 
was  repeated  in  two  hours  more.  Her  pains  became  more  violent; 
she  had  much  fever,  attended  with  delirium. 

I  was  now  sent  for  a  second  time;  upon  examining  the  patient, 
the  uterus  appeared  evidently  to  have  been  forced  into  contrac- 
tions by  the  fright,  and  these  perpetuated  by  the  improper  con- 
duct of  the  midwife;  but  things  were  now  in  such  a  situation, 
that  it  would  have  been  in  vain  to  have  attempted  stopping  the 
progress  of  the  labour. 

The  mouth  of  the  uterus  was  thick  and  hard,  and  opened  to 
about  the  size  of  half  a  dollar.  As  there  was  so  much  fever,  I 
thought  proper  to  bleed  and  purge  her ;  these  had  a  good  effect, 
as  her  fever  and  delirium  were  diminished,  but  the  mouth  of  the 
uterus  was  firm,  and  not  augmented  in  size  since  she  was  exami- 
ned before,  (six  hours;)  she  was  again  bled  pretty  largely,  the 
delirium  went  off  entirely,  the  uterus  opened,  and  she  was  deliv- 
ered in  less  than  an  hour. 

997.  Had  not  this  patient  been  bled  very  liberally,  there  is 
every  reason  to  believe  her  labour  would  have  had  a  serious  ter- 
mination— she  lost  in  the  two  bleedings  about  fifty  ounces  of 
blood.  This  case  serves  as  a  contrast  to  the  one  just  before  re- 
lated ;  as  I  believe  the  bleeding  which  preceded  the  anodyne 
enema,  enabled  the  latter  to  produce  its  beneficial  effects ;  and  I 
am  also  of  opinion,  that  had  a  bleeding  been  premised  in  this 
case,  the  patient  would  have  suffered  much  less,  and  gone  some 
time  longer. 


364  CICATRICES,  &C.    FROM  LOCAL  /nJURIES. 

998.  I  think  it  an  important  rule  in  the  farther  arrangement 
of  these  labours,  when  pain  cannot  be  suspended  by  the  means 
pointed  out  alx)ve,  to  abstract  stimuli  of  every  kind,  as  much  as 
possible  ;  to  have  the  bowels  well  opened;  and  then  to  allow  the 
circular  fibres  of  the  mouth  of  the  uterus  to  be  a  little  fatigued, 
before  we  employ  a  larger  or  sufficient  bleeding  to  effect  the  far- 
ther dilatation.  We -may  easily  know  when  they  begin  to  be  fa- 
tigued, by  their  readily  yielding  when  the  finger  attempts  to 
stretch  it  in  the  absence  of  pain.  Bleeding  alone  sometimes 
quiets  this  premature  motion  of  the  uterus. 

Sect.  III. — Cicatrices  or  other  Imjoerfections  arising  frotn 
Local  Injuries. 

999.  It  was  not  until  the  year  1796  that  I  learnt  the  value  and 
certainty  of  blood-letting  in  cases  of  local  injur)^  from  inflamma- 
tion, or  from  a  solution  of  continuity  in  the  soft  parts  concerned 
in  labour,  where  in  healing  they  became  contracted,  and  other- 
wise severely  injured,  though  I  had  so  frequently  experienced 
its  value  in  cases  where  they  had  obstinately  refused  to  yield  to 
the  common  agents  of  delivery,  when  in  the  natural  condition. 
The  long  continued  pressure  of  the  child's  head  during  its  pas- 
sage; the  ill-judged  use,  and  the  worse  directed  application  of 
instruments;  and  the  reprehensible  neglect  of  the  perin^eum  when 
much  distended — have  given  rise  to  more  or  less  grievous  injuries 
of  these  parts.  These  accidents  will  retard  delivery  in  propor- 
tion to  their  extent ;  and  if  some  oppose  but  a  trifling  resistance 
to  the  passage  of  the  child,  there  are  others,  from  their  severity 
and  extent,  which  may  render  it  impossible  without  adventitious 
aid. 

1000.  Cutting  instruments  have  been  not  only  considered  as 
justifiably  employed  in  such  cases,  but  deemed  absolutely  essen- 
tial for  the  termination  of  the  labour,*  in  many  instances  where 
bridles,  indurations,  and  cicatrices  have  deranged  the  natural  or- 
der of  these  parts,  or  so  disturbed  their  natural  functions,  as  to 
render  them  no  longer  subservient  to  their  proper  uses — hence 
the  necessity  of  means  so  severe  as  the  scalpel  or  bistoury  for  the 
relief  of  the  mother  and  child. 

1001.  I  trust,  however,  this  terrible  alternative  is  no  longer,  or 
at  least,  not  so  frequently  necessary  as  heretofore;  since,  it  is 

*  Baudelocque,  &c. 


CICATRICES,  &c.  ruo:\r  local  injuries.  365 

found,  in  some  of  the  most  distressing  and  extensive  injuries  of 
this  kind,  to  yield  in  a  very  short  time  to  the  relaxing  influence 
of  a  copious  bleeding.  To  show  the  certainty  of  this  reme- 
dy, even  under  the  most  unpromising  circumstances,  I  will 
relate  several  cases  where  it  was  employed  with  the  happiest 
effects. 

Case  First. 

1796,  June,  I  was  called  to  Mrs.  T ,  in  labour  with  her 

second  child.     When  I  arrived,  I  received  the  following  account 

of  the  case  from  the  midwife:  "Mrs.  T has  been  in  labour 

sixteen  hours;  the  waters  discharged  six;  the  mouth  of  the  womb 
is  but  little  opened;  and,  when  in  pain,  the  os  externum  seems  to 
close  up;  the  child  is  as  high  as  ever,  though  many  things  have 
been  given  to  force  the  labour.  She  has  passed  no  water  for 
twelve  hours,  and  she  is  very  costive." 

I  found  her  very  feverish;  complaining  of  great  heat  in  her  ab- 
domen, and  violent  pain  in  her  head.  On  examining  per  vagi- 
nam,  I  found,  as  the  midwife  had  stated,  that  the  os  tineas  was 
but  little  dilated;  its  edges  very  rigid  and  hot — as  was  the  whole 
tract  of  the  vagina;  the  rectum  much  distended  with  faeces,  and 
the  bladder  by  urine.  The  head  of  the  child  was  still  above  the 
brim  of  the  superior  strait;  but  its  situation  could  not  be  exactly 
determined,  as  the  os  uteri  was  not  sufficiently  opened  for  the 
purpose. 

She  was  bled  immediately,  to  the  amount  of  twelve  or  fourteen 
ounces,  and  an  injection  was  thrown  up,  which  procured  two 
stools  and  a  discharge  of  urine.  Upon  examination,  I  found  the 
mouth  of  the  uterus  more  dilated;  and  I  was  enabled  to  deter- 
mine, that  the  presentation  was  a  perfectly  natural  one ;  and  the 
head  lower  in  the  pelvis.  The  pains  were  very  powerful;  the 
head  at  length  cleared  the  upper  strait,  and  the  vertex  was  about 
to  turn  under  the  arch  of  the  pubes,  but  completely  enveloped  in 
the  uterus — during  a  pain,  the  perinaeum  was  much  distended ; 
the  OS  externum,  instead  of  yielding  to  the  impulsive  force  of  the 
uterus,  rather  closed,  so  that  two  fingers  could  not  be  retained  at 
once.  A  seam,  or  cicatrice,  formed  a  kind  of  barrier  in  the  vagi- 
na; and  the  head  in  consequence,  was  thrown  to  the  right  side  of 
the  inferior  strait;  where  the  parts  were  so  extremely  stretched, 


366  CICATRICES,  &C.  FROM  LOCAL  INJURIES. 

that  I  feared  at  each  pain,  the  head  would  burst  through  them, 
in  spite  of  every  exertion  to  the  contrary.* 

From  the  oblique  situation  of  the  head  with  respect  to  the  va- 
gina, the  OS  externum,  instead  of  answering  to  the  axis  of  the 
inferior  strait,  was  mounted  up  directly  to  the  pubes;  conse- 
quently the  right  side  of  the  vagina,  perinseum,  and  rectum,  had 
to  support  the  greater  part  of  the  force  exerted  by  the  uterus  and 
its  auxiliary  powers.  In  order  to  counteract  their  influence,  I 
supported  the  external  parts  with  my  hands;  and  made,  during 
each  pain,  a  strong  pressure  against  the  head;  directing  the  wo- 
man at  the  same  time  to  suspend  her  voluntary  powers,  as  much 
as  possible. 

Six  hours  were  spent  in  this  manner  without  advantage;  the 
OS  uteri  still  rigid,  hot,  and  but  partially  dilated;  the  os  externum 
not  disposed  to  yield,  and  the  cicatrix  as  firm  as  ever.  The  head 
advanced,  notwithstanding  my  efforts  to  prevent  it;  so  that  the 
vertex,  covered  with  the  uterus  had  partly  emerged  from  under 
the  arch  of  the  pubes.  At  this  period  it  was  extremely  difficult 
to  touch  the  mouth  of  the  uterus;  as  it  had  receded  towards  the 
.sacrum,  in  proportion  as  the  vertex  had  descended. 

The  soft  parts  were  very  hot  and  dry;  and  I  began  to  enter- 
tain serious  apprehensions  for  the  patient.  I  was  ten  miles  from 
the  city,  and  no  one  was  near,  on  whose  judgment  I  could  rely. 
In  this  dilemma  I  had  neai'ly  resolved  to  divide  the  parts;  believ- 
ing it  preferable  to  permitting  the  head  to  force  its  way  through 
them;  which  I  began  to  consider  as  inevitable;  when  fortunate- 
ly Dr.  Physick's  case  of  luxated  humerus  occurred  to  me.  This 
determined  me  to  try  the  effects  of  bleeding,  ad  deliquium  ani- 
mi.  I  represented  to  the  friends  of  the  patient,  the  danger  of  her 
case;  the  ^05.s/6/e  result  of  the  bleeding;  and  the  inevitable  one 
did  it  not  succeed.  They  agreed  to  the  trial.  I  had  the 
patient  placed   on   her   feet,    while   the    midwife   firmly   sup- 

•  The  cicatrix  just  spoken  of,  was  formed  by  the  heahng  up  of  an  extensive 
laceration  which  tlie  patient  sufTcrcd  in  her  former  labour.  It  ran  from  the  in- 
ferior termination  of  the  left  labium,  to  about  tiie  termination  of  the  sacrum.  I 
judged  of  the  extent  of  the  injury,  by  the  cicatrix;  and  tliis  could  be  traced  to 
this  point.  Conversing  upon  this  case,  some  time  after,  with  the  practitioner 
who  had  delivered  her  before,  he  confirmed  my  supposition.  It  was  a  long 
time  before  the  wound  healed;  and  the  woman's  health  suffered  much  from  the 
excessive  and  long-continued  discharge;  but  fi-om  this  she  recovered:  and  was 
when  I  was  called  to  her,  apparently  in  robust  health.  She  was  about  twenty- 
iwo  years  of  age;  of  short  stature,  and  rigid  fibre. 


i 


CICATRICES,  &C.  FROM  LOCAL  INJURIES.  367 

ported  the  perina^um,  &c,  A  vein  was  opened;  and  allowed  to 
bleed,  until  she  fainted. ''  She  was  now  placed  on  her  side  in  the 
bed. 

On  examining  her,  everything  appeared  better;  the  external 
parts  were  perfectly  soft  and  yielding;  and  the  os  uteri  pretty 
fully  dilated  ;  but  no  pains  succeeded,  during  the  time  I  thought 
proper  to  wait;  (which  was  half  an  hour,  the  patient  continuing 
very  faint  all  this  time ;)  the  parts  being  now  in  a  proper  situation 
for  delivery,  I  introduced  the  forceps;  and  delivered  a  living,  and 
healthy  child.  The  parts  yielded  very  readily  without  lacera- 
tion; and  the  woman  had  a  rapid  recovery. 

1002.  As  cases  of  the  kind  I  am  now  considering,  are  highly 
interesting;  both  from  the  extent  of  injury  done  to  the  parts, 
and  their  rarity,  I  trust  I  shall  be  excused  for  detailing  another; 
especially,  as  the  mode  of  treating  them  is  as  certain,  as  it  is 
novel,  t 

Case  Second. 

On  the  12th  September,  1798, 1  was  requested  to  visit  the  wife 
of  Samuel  G.,  in  consultation  with  Dr.  Jones.  I  was  informed  by 
the  doctor,  that  Mrs.  G.  had  been  in  labour  sixteen  hours;  the 
waters  evacuated  themselves  early;  her  pains  were  frequent  and 

*  The  quantity  of  blood  drawn  was  upwards  of  two  quarts. 

\  Dr.  Davles  gives  the  credit  of  large  bleedings  In  pai-tiu-itlon  to  the  late  Dr. 
Rush.  1  feel  that  I  am  entitled  to  whatever  praise  or  blame  may  attach  to  this 
practice.  But  this  has  been  long  since  ceded  to  me  by  that  gentleman,  with  all 
that  frankness  and  liberality  which  so  constantly  characterized  him.  But  Dr. 
Davles  does  not  appear  to  understand  the  ch'cumstances  under  which  this  prac- 
tice Is  recommended.  I  Infer  this  from  his  observations  on  the  use  of  blood-let- 
ting, where  rigidity  is  a  cause  of  difficulty. 

"For  my  own  part,"  says  he,  "lean  see  no  good  reason  for  bleeding  pro- 
spectively, or  In  anticipation  of  a  mere  possibility,  which  miglitor  might  not  be 
realized  by  the  event.  To  say  the  least  of  such  a  practice,  it  would  appear  to 
be  a  most  unnecessary  encroachment  upon  the  ordiniuy  dispositions  of  nature  in 
the  affairs  of  a  function  which  she  usually  performs  very  safely  and  satisfactorily 
without  any  such  Interference." — Elem.  of  Oper.  Mid,  p.  89. 

This  passage  would  lead  to  the  conclusion  that  I  recommend,  (for  It  Is  not  Dr. 
Rush,)  this  operation  previously  to  any  appearance  of  the  necessity;  which  is 
far  from  being  the  case.  This  opinion  Is  strengthened  by  what  Immediately 
follows;  "Bleeding  on  the  other  hand,  as  a  j-cmedy  or  a  corrective  of  an  actu- 
ally existing  rigidity  of  the  soft  parts,  whetlier  or  not  accompanied  by  more  than 
ordinary  constitutional  excitement,  is  a  power  of  great  and  unquestionable  val- 
ue." p.  90.  Now  this  is  conceding  all  that  I  have  ever  contended  for  in  the 
use  of  this  remedy. 


368  CICATRICES,  &C.    FROM  LOCAL  INJURIES. 

strong  ;  but  there  was  not  the  least  disposition  in  the  soft  parts  to 
dilate* 

I  examined  the  patient,  and  found  the  os  externum  scarcely 
large  enough  to  admit  the  finger,  and  mounted  against  the  sym- 
physis pul)is,  in  consequence  of  the  perinseum  being  very  much 
distended  by  the  head  of  the  child.  The  os  uteri  was  rigid,  and 
but  little  opened;  a  kind  of  bridle,  or  small  column  of  flesh  ran 
from  the  inferior  edge  of  the  symphysis  pubis,  and  lost  itself  in 
the  perinseum  below ;  against  this  the  head  was  firmly  pressed. 
The  head  was  situated  naturally;  and  so  far  advanced,  that  the 
vertex  was  about  to  emerge  from  under  the  arch  of  the  pubes, 
covered  with  the  uterus;  and  had  been  in  this  situation  six  hours 
previous  to  my  visit.  All  that  had  been  done  during  this  period, 
was  the  occasional  exhibition  of  laudanum,  with  a  steady  pressure 
against  the  perinajum,  to  prevent  the  head  escaping  through  it. 
In  this  situation  of  things  what  was  to  be  done? 

My  ingenious  and  much  lamented  friend.  Dr.  Elihu  Smith,  of 
New  York,  upon  the  receipt  of  the  history  of  the  case  just  re- 
lated, suggested  the  trial  of  an  infusion  of  tobacco  in  similar  cases, 
as  a  substitute  for  such  extensive  bleeding;  affirming  the  effects 
were  very  like  those  produced  by  copious  blood-letting;  such  as 
nausea,  vomiting,  syncope,  and  relaxation.  I  was  pleased  with 
the  idea;  and  determined  to  employ  it  the  first  opportunity — the 
case  under  consideration  I  believed  to  be  as  favourable  a  one 
as  could  well  occur;  I  accordingly  proposed  the  tobacco  infusion 
to  Dr.  Jones,  who  cheerfully  consented  to  its  trial. 

A  strong  infusion  of  tobacco,  after  several  inefiectual  attempts, 
was  thrown  up  the  rectum;  it  produced  great  sickness,  vomiting, 
and  fainting;  but  the  desired  relaxation  did  not  take  place — we 
waited  some  time  longer,  with  no  better  success.  In  the  course 
of  an  hour,  or  an  hour  and  a  half,  the  more  distressing  effects  of 


*  This  patient  like  the  one  whose  case  has  just  been  related,  had  also  suffei-- 
ed  a  laceration  of  great  extent;  the  parts,  after  a  considerable  lapse  of  time, 
liealed;  but  so  unfortunately,  as  almost  entirely  to  obliterate  the  vag-ina.  I  was 
called  upon  for  advice;  the  woman's  situation  was  truly  distressing;  the  pas- 
sage, or  vagina,  was  so  much  contracted,  as  not  to  exceed  In  size  a  common 
writing  quill;  the  parts  extremely  callous;  and  a  continual  and  profuse  dis- 
charge of  acrid,  fcrtid  pus,  kept  her  in  a  constant  state  of  misery,  and  ill-healtli. 
My  friend,  Dr.  Physick,  was  also  consulted  at  the  same  time:  by  a  persevering 
use  of  sponge  tents,  &.c.  the  parts  became  sufficiently  dilated  to  admit  Imper- 
fectly the  venereal  congress;  soon  after,  she  became  pregnant;  and  the  conse- 
quences of  this  pregnancy,  furnish  the  above  case. 


CICATRICES,  &C.  FROM  LOCAL  INJUUIES.  3G9 

the  infusion  wore  off;  but  resolved  to  give  the  remedy  every 
chance  in  our  power,  wc  prevailed  on  the  patient,  with  some 
difficulty,  to  consent  to  another  trial  of  it;  its  effects  were  the 
same  as  before — great  distress,  without  the  smallest  benefit;  the 
parts  remaining  as  rigid  as  before  its  exhibition. 

Supposing  the  bridle  just  spoken  of,  might  have  some  influence 
on  the  developement  of  the  parts,  I  divided  it,  but  without  any 
evident  good.  We  now  proposed  the  remedy  that  had  so  com- 
])letely  succeeded  in  the  former  case — namely,  bleeding  nearly  to 
tainting;  to  this  the  patient  consented.  We  placed  the  patient  on 
her  feet,  taking  care  to  have  the  perinaeum  guarded,  during  the 
operation.  Upon  taking  away  about  ten  ounces  of  blood,  she  be- 
came very  faint;*  she  was  immediately  laid  upon  the  bed;  and 
the  most  complete  relaxation  had  taken  place;  the  forceps  were 
applied,  and  our  patient  was  delivered  in  a  few  minutes  of  a  fine 
healthy  girl.  The  mother  v.'as  comfortably  put  to  bed;  and 
everything  went  on  in  the  ordinary  way  until  the  sixth  day;  at 
which  time,  she  was  seized  with  a  violent  cholera  morbus,  and 
convulsions,  (to  which  complaints  she  was  subject,)  and  died  in 
twelve  hours. 

This  case,  notwithstanding  its  unfortunate  termination,  fully 
establishes  the  influence  of  blood-letting  in  this  very  distressing 
kind  of  rigidity;  and  jjroves  its  action  to  be  different  from  that 
of  tobacco;  though  the  latter  produces  sickness,  vomiting,  and 
syncope.  I  do  not  think  the  slightest  blame  can  attach  to  the 
bleeding;  as  the  woman  was  very  well  unto  the  sixth  day;  when 
diseases  to  which  she  was  subject,  supervened,  and  carried  her  ofi'. 

Case  Third. 

On  the  26th  September,  1800,  I  was  called,  in  consultation 
with  Dr.  Ruan,  to  a  woman  in  labour.  She  had  been  twelve  or 
fourteen  hours  in  travail  with  her  second  child. t  The  pains  were 
frequent  and  strong;  the  waters  had  been  discharged  some  time; 
the  head  was  fiivourably  situated,  and  completely  occupied  the 
vagina;  the  perinseal  tumour  large;  the  os  externum,  which  did 
not  exceed  in  size  a  fmger  ring,  admitted  the  finger  with  some 
difficulty,  in  the  absence  of  pain;  during  a  pain  it  would  be 

*  The  subject  of  this  case  was  a  delicate  woman,  and  wont  to  become  very 
faint  upon  the  loss  of  a  little  blood. 

f  Witli  the  first  she  had  suffered  an  extensive  laceration  of  the  perinaeum. 
47 


370  RELATIVE  RIGIDITY. 

thrown  up  against  the  inferior  edge  of  the  symphysis  pubis,  so  as 
not  to  admit  the  finger,  or  permit  it  to  remain,  if  it  had  been  pre- 
viously introduced.  Externally,  a  large  cicatrix  was  found  to 
run  to  the  very  verge  of  the  anus  ;  internally,  it  could  be  traced 
farther.  This  seam  prevented  the  unfolding  of  the  external 
parts  so  effectually,  that  the  repeated  efforts  of  the  uterus  for 
several  hours  were  insufficient  to  make  them  yield ,  though  the 
head  had  been  closely  applied  to  them  for  that  period. 

The  patient  was  a  strong  healthy  woman — considerable  fever 
— the  pulse  strong,  frequent,  and  hard.  I  proposed  bleeding  ad 
deliquium,  to  which  Dr.  Ruan  consented.  A  vein  was  opened 
immediately,  and  we  took  away  about  fourteen  ounces  of  blood; 
but  as  the  pains  were  very  rapid,  we  were  obliged  to  draw  it 
while  she  was  in  a  recumbent  posture  ;  no  disposition  to  syncope 
was  manifested.  This  quantity,  however,  had  some  effect,  as  there 
was  evidently  a  disposition  in  the  parts  to  relax,  and  an  abate- 
ment of  the  severity  and  frequency  of  the  pains.  A  second  bleed- 
ing was  determined  upon,  and  to  perform  it  while  the  patient  was 
in  an  erect  position.  We  effected  this  with  some  difficulty,  but 
upon  taking  five  and  twenty  or  thirty  ounces  of  blood  more,  she 
fainted — she  was  laid  on  the  bed,  and  in  a  few  minutes  was  de- 
livered by  the  forceps,  of  a  fine  healthy  boy — the  patient  reco- 
vered rapidly,  without  accident.  About  three  years  after,  I  again 
delivered  the  same  person  by  the  same  means. 

Relative  Rigidity. 

1003.  I  have  maintained  that  not  only  the  different  parts  of  the 
uterus  into  which  it  is  usually  divided,  may  act  separately  and 
independently  of  each  other,  but  that  even  the  different  sets  of 
fibres  of  which  it  is  composed  may  do  the  same;  hence  that  pecu- 
liar rigidity  1  have  denominated  "relative;"  by  this  we  are  to 
understand  that  the  circular  fibres  act  with  a  force  superior  to  the 
longitudinal.  This  may  happen  from  the  latter  losing  a  portion 
of  their  strength,  which  will  necessarily  give  to  the  circular  a  re- 
lative superiority  of  force;  or  it  may  happen  that  the  circular 
fibres  from  some  cause  or  other,  may  have  an  increase  of  power, 
which  will  of  course,  make  the  longitudinal  relatively  weaker. 
Whichever  way  it  may  take  place,  the  result  is  the  same,  for 
the  labour  will  become  stationary. 

1004.  This  case  may  be  known  by  labour  coming  on  kindly, 
but  after  a  certain  period,  gradually  diminishing  in  force,  by  the 


TONIC  RIGIDITY.  dn 

mouth  of  the  uterus  having  a  disposition  to  dilate;  by  its  thicken- 
ing; by  the  presenting  part  not  protruding  during  a  pain;  by  pain 
extending  itself  OA'er  the  whole  abdomen;  by  a  sense  of  suffoca- 
tion; by  a  hard,  full,  depressed  pulse;  by  the  irregularity  of 
the  pains,  both  in  force  and  frequency — the  mouth  of  the  uterus 
in  this  case  cannot  open  agreeably  to  the  order  of  nature,  as  the 
fibres  destined  to  keep  it  shut,  are  relatively  stronger  than  those 
intended  to  open  it. 

1005.  In  consequence  of  this  transfer,  or  peculiar  disposition  of 
the  power,  the  longitudinal  fibres  contract  more  feebly  and  tran- 
sitorily; the  mouth  of  the  uterus  does  not  dilate,  though  not  pre- 
ternaturally  rigid;  the  abdominal  tumour  does  not  continue  to  sub- 
side; there  is  a  secretion  of  m.ucus,  and  a  disposition  in  the  exter- 
nal parts  to  relax;  but  the  os  uteri  cannot  dilate  until  the  longi- 
tudinal fibres  have  shaken  off  their  torpor,  or  in  other  words,  not 
until  the  cause  of  this  torpor  is  removed;  when  this  is  done,  they 
resume  their  healthy  contractions,  and  the  labour,  for  the  most 
part,  is  quickljr  terminated. 

Case. 

Mrs.  W ,  June  10th,  1S05,  was  taken  in  labour  with  her 

tenth  child:  her  pains  began  smartly,  but  soon  ceased  almost  en- 
tirely— she  continued  in  this  situation  from  ten  o'clock  in  tiie  eve- 
ning until  six  the  next  morning;  at  this  time  I  was  called;  I  found 
her  with  nearly  all  the  symptoms  above  enumerated ;  she  was  bled 
twenty  ounces;  pains  came  on  immediately,  and  she  was  quickly 
delivered. 

Sect,  IV. —  To7iic  Rigidity;  or  Rigidity  from  the  Premature 
Escape  of  the  Waters. 

1006,  This  only  takes  place  after  the  waters  have  been  a  long 
time  discharged — the  tonic  contraction  of  the  uterus  then  becomes 
powerful,  and  its  force  will  be  in  proportion  to  the  healthy  dispo- 
sition of  ibis  organ;  and  the  time  which  may  have  elapsed  since 
the  waters  were  drained  off.  I  have  already  remarked  upon  this 
disposition  of  the  uterus  when  freed  from  its  contents,  and  stated 
its  high  and  important  uses,  to  the  woman  at  the  time,  (251 ;)  I 
have  also  referred  to  the  inconveniences  to  v/hich  it  sometimes 
gives  rise,  when  speaking  of  the  causes  of  preternatural  labours, 
and  given  a  case  illustrative  of  it.  (678)    Cases  of  this  kind  have 


372  TONIC  RIGIDITV. 

frequently  occurred  to  me;  but  in  some  I  have  been  obliged  to 
turn  after  bleeding,  (which  was  impossible  before,)  and  in  one  or 
two  others  I  have  been  obliged  to  use  the  forceps. 

1007.  There  is  a  kind  of  rigidity,  or,  more  properly  speaking, 
a  cartilaginous  or  scirrhous  condition  of  the  neck  or  mouth  of  the 
uterus,  which  is  so  confirmed  and  indurated,  as  not  to  yield  to  the 
powers  of  the  body  and  fundus,  nor  to  blood-letting,  however  far 
it  may  be  carried.  These  cases,  fortunately,  are  very  rare;  so 
rare,  indeed,  that  I  have  never  met  with  an  instance  of  the  kind. 
They  are,  however,  recognized  by  Baudelocque  and  other  writers. 

1008.  Baudelocque  says  of  them:  "Sometimes  the  pad  which 
constitutes  the  neck  of  the  uterus,  in  the  latter  periods  of  preg- 
nancy, and  in  time  of  labour,  is  hard,  scirrhous,  incapable  of  any 
extension  or  dilatation,  so  as  entirely  to  hinder  the  exit  of  the  child. 
After  a  convenient  delay  to  ascertain  that  the  efforts  of  nature 
cannot  overcome  the  resistance,  and  the  administration  of  proper 
methods  to  relax  it,  it  must  be  cut  in  several  places,  as  some  prac- 
titioners have  done.  These  incisions  are  preferable  to  rents  which 
might  take  place  in  it,  and  have  never  been  attended  with  the 
same  consequences.  They  must  be  made  more  or  less  extensive, 
according  to  the  pad,  which  is  callous:  but  always  so  much  so, 
that  the  orifice  may  afterwards  open  sufficiently."* 

1009.  The  success  of  this  plan  has  been  verified,  in  this  coun- 
try, as  the  case  of  Dr.  Thomas  Archer  most  satisfactorily  proves. 
Dr.  A.  was  called  to  a  woman  in  the  thirtieth  year  of  her  age,  and 
in  labour  with  her  first  child.  The  os  uteri  was  found  to  be  very 
little  opened,  "and  forming  a  thick  cartilaginous  ring,  which  nei- 
ther yielded  to  nor  was  softened  by  the  pains."  After  ordering  a 
bleeding  to  some  extent,  to  be  purged,  &c.  he  took  his  leave,  and 
left  her  to  the  midwife  who  had  charge  of  her.  He  did  not  see 
this  patient  again  until  late  in  the  following  day.  Soon  after  his 
arrival,  the  uterus,  loaded  with  its  contents,  was  pushed  through 
the  OS  externum.  The  child  was  dead  he  thought,  beyond  doubt, 
and  had  most  probably  been  so  for  ten  days.  As  the  case  appeared 
to  him  hopeless,  and  as  it  was  not  in  his  power  to  procure  a  con- 
sultation, he  resolved  on  making  incisions  in  the  mouth  of  the 
uterus;  he  accordingly,  by  means  of  a  common  lancet,  made  three 
cuts  in  the  uterine  circle;  one  anterior,  one  posterior,  and  one  la- 
terally.    The  incisiens  were  each  about  two  inches  long.     The 

*  Vol.  III.  p.  205. 


OVER-BISTENTION  OV  THE  UTERUS.  373 

pains,  though  not  strong  at  this  time,  were  sulEcient,  however,  to 
expel  the  child  almost  instantaneously.  The  woman  was  put  to 
bed,  and  no  unpleasant  symptom  followed.* 

1010.  In  addition  to  this  case,  and  as  confirmatory  of  its  suc- 
cess, we  may  mention  those  of  Moscati.  A  woman  whose  os 
uteri  had  suffered  from  a  previous  labour,  was  found  at  the  time 
of  her  second,  to  be  so  restricted  and  dense  as  to  require  an  ope- 
ration. This  was  performed  by  making  several  incisions  in  the 
circle  of  the  os  uteri,  which  dilated  after  a  time  sufficiently,  and 
without  farther  injury,  to  permit  the  child  to  pass — this  operation 
was  repeated  upon  another  occasion  on  the  same  vvoman  with 
similar  success.  This  method  Moscati  thinks  better  than  that 
recommended  by  Smellie,  and  appears  to  consider  it  original. t 
But  the  above  case  will  show  that  Dr.  Archer  had  performed  this 
very  operation  long  before,  and  with  equal  advantage. 

Sect.  V.  and  VI. —  Over-distent  ion  of  the  Uterus^  and  the 
Memhranes  too  Dense,  as  a  Cause  of  Tedious  Labour. 

1011.  In  many  cases  of  this  kind,  a  well-directed  interference 
may  very  much  abridge  the  duration  of  suffering;  but  when  and 
how  to  interfere,  with  success,  can  only  he  known,  by  those  who 
possess  correct  principles,  and  have  had  long  experience.  Thus 
Mr.  Burns  telis  us,  and  to  the  success  and  truth  of  which  we 
can  bear  ample  testimony,  "  that  in  many  cases  a  very  moderate 
resistance,  retards  the  expulsive  process,  and  renders  the  pains 
irregular  or  inefficient.  And  I  know  by  experience  that  the 
membranes  may  be  so  tough  as  not  readily  to  give  way,  and  in 
this  case  the  pains  become  less  effective,  and  the  labour  is  protract- 
ed till  they  be  opened.  Whenever  the  resistance  is  removed,  the 
pains  become  brisk  and  forcing." 

1012.  Of  cases  of  this  kind,  we  have  seen  many;  but  one  of  the 
most  remarkable  happened  in  September,  1826.  Mrs.  — ,  at 
the  full  period  of  her  pregnancy,  as  she  calculated,  was  attack- 
ed on  the  eighteenth  of  August,  with  severe  alternate  pains,  which 
caused  me  to  be  sent  for.  These  pains  were  excessively  severe; 
bu-t  without  either  force  or  regularity.  There  was  no  secretion 
of  mucus,  nor  was  the  os  uteri  dilated,  though  soft,  and  the  whole 
of  the  inferior  portion  of  the  uterus  was  excessively  distended  and 

•  Med.  and  Phys.  Jour.  Vol.  I.  p.  157. 

t  See  Bidletine  Universal,  &c.  No.  6,  July,  1827. 


374  OVER-DISTENTION  OP  THE  UTERUS. 

very  thin.  After  waiting  several  hours,  not  the  least  alteration 
was  observed,  though  the  pains  had  continued  with  much  severity. 
I  ordered  a  gill  of  water  and  a  drachm  of  laudanum  to  be  given 
as  an  enema.  This  application  completely  tranquillized  the  pains 
for  many  hours;  they  however  returned,  with  as  much  violence 
the  day  following;  and  were  again  relieved  by  the  same  remedy; 
nor  did  they  return  until  the  21st  of  September,  nearly  five  weeks 
from  the  first  attack. 

1013.  This  second  attack  was  every  way  similar  to  the  first, 
with  the  addition  of  an  acute  pain  in  the  right  side,  which  was 
augmented  by  coughing,  or  a  full  inspiration.  Twelve  ounces  of 
blood  were  drawn  ;  the  bowels  freely  opened  by  epsom  salts  and 
calcined  magnesia;  and  the  diet  and  drink  restricted  to  barley- 
water.  The  condition  of  the  uterus  was  very  much  the  same  as 
it  was  when  examined  on  the  18th  of  August.  The  bleeding  and 
purging  afforded  much  relief,  by  removing  the  pain  from  the 
side;  but  there  was  no  abatement  of  the  uterine  action,  or  pain; 
for  such  it  certainly  was,  as  the  whole  uterine  globe  was  found 
firmly  contracted  or  hardened  at  each  pain.  The  laudanum  ene- 
ma was  repeated  with  the  previous  good  effect,  and  my  patient 
remained  quiet  until  the  day  but  one  following,  namely,  the  23d, 
when  there  was  again  a  renewal  of  the  previous  symptoms,  which 
were  again  removed  by  bleeding,  purging  and  laudanum.  On 
the  24th,  the  same  sufferings  were  endured,  and  relieved  as  be- 
fore. On  the  25th,  my  patient  was  again  seized  at  the  hour  with 
the  same  symptoms,  together  with  great  feebleness,  and  almost 
constant  disposition  to  syncope.  The  pains  were  occasionally  se- 
vere, but  far  apart;  not  at  all  protrusive;  and  each  was  followed 
by  nearly  complete  syncope. 

1014.  The  situation  of  my  patient  seemed  now  to  call  for  some 
efficient  relief,  or  she  must  succumb.  As  the  uterus  was  very 
thin  and  much  stretched,  and  the  os  uteri  was  pliant,  though  not 
-dilated  beyond  three-quarters  of  an  inch,  I  thouglit  it  would  be 
best  to  rupture  the  membranes,  and  give  an  opportunity  to  the 
uterus  to  contract,  and,  as  I  believed,  remove  tlie  disposition  to 
syncope;  this  was  accordingly  done;  and  it  gave  issue  to  an  im- 
mense quantity  of  liquor  amnii.  My  patient  received  immediate 
benefit  from  this  operation ;  the  sensation  of  distention  was  re- 
lieved, and  the  faintness  was  instantly  removed.  In  about  half 
an  hour,  the  pains  became  efficient,  and  the  os  uteri  began  to  di- 
late ;  and  in  about  an  hour  and  a  half,  my  patient  was  safely  de- 


OVER-DISTENTION  OF  THE  UTEKUS.  375 

livered  of  a  large  male  child.     No  aflcr-inconvenicnce  was  expe- 
rienced. 

1015.  This  case  is  remarkable  for  the  numerous  unsuccessful 
efforts  the  uterus  made  to  disembarrass  itself,  and  the  severe  suf- 
ferings the  patient  underwent  during  these  efforts;  and  may 
with  as  much  certainty  as  almost  any  with  which  I  am  acquaint- 
ed be  looked  upon  as  a  protracted  case  of  gestation.*  The  pa- 
tient considered  her  term  as  having  fully  expired  on  the  18th  of 
August;  the  period  at  which  pains  first  manifested  themselves; 
and  as  far  as  the  usual,  mode  of  reckoning,  and  the  complete  de- 
velopement  of  the  uterus  at  that  time  can  be  relied  on,  incline  us 
to  the  belief,  that  she  was  correct;  and  that  she  really  had  ar- 
rived at  ten  months  and  a  week,  complete,  when  delivery  took 
place. 

1016.  I  can  anticipate  nothing,  even  at  this  moment,  but  a  dis- 
astrous issue,  had  I  neglected  to  rupture  the  membranes;  as 
several  very  distressing,  as  well  as  alarming  symptoms,  had  be- 
gun to  show  themselves;  such  as  a  cold,  clammy  skin  ;  a  small, 
frequent  pulse;  laborious  breathing,  and  great  proneness  to  syn- 
cope ;  all  of  which  were  instantly  removed  by  taking  off  the  dis- 
tention of  the  uterus,  by  giving  an  opportunitj^  for  the  liquor  am- 
nii  to  escape  by  rupturing  the  membranes.  This  case  must  not 
be  confounded  with  the  Hydroamnios  or  a  dropsy  of  the  ovum 
one  of  the  few  diseases  to  which -it  is  liable.  It  is  almost  always 
caused,  as  far  as  my  experience  goes,  by  a  latent  venereal  taint 
on  the  side  most  frequently  of  the  father,  and  this,  for  reasons  that 
will  immediately  present  themselves.  In  these  cases  the  woman 
rarely  goes  to  the  full  period  of  utero-gestation — for  the  foetus  is 
sometimes  expelled  as  early  as  the  sixth  month,  and  rarely  goes 
beyond  the  beginning  of  the  eighth.  It  is  usually  found  to  be  dead, 
or  so  weak  as  to  die  very  soon  after  birth.  In  some  instances  the 
liquor  amnii  is  so  abundant  as  to  give  the  woman  the  appearance 
of  being  at  the  full  time,  though  she  may  not  have  exceeded  the 
seventh  month.  We  have  had  several  such  patients  under  our 
care — in  one  of  these  seven  dead  children  were  delivered  in  as 
many  consecutive  pregnancies.  This  case,  with  several  similar, 
the  uterus,  &c.  were  restored  to  the  healthy  performance  of  their 
duties,  by  mercury,  and  sarsaparilla,  in  the  unimpregnated  interval. 

*  See  Chapter  "  On  the  Term  of  Utero-Gestation." 


376 


CHAPTER  XXXI. 

IliEMORRHAGE  FROM  THE  SITUATION  OF  THE  PLACENTA  OVER  THE 
MOUTH  OF  THE  UTERUS. 

1017.  I  SHALL  confine  my  observations  on  the  subject  of  uterine 
haemorrhage  in  this  place,  to  the  "  unavoidable  species"  and  to 
those  discharges  of  blood  which  follow  the  birth  of  the  child;  and 
will  refer  my  reader  for  an  account  of  such  as  precede  delivery, 
but  in  which,  the  placenta  is  not  situated  over  the  mouth  of  the 
uterus,  to  my  work  on  the  Diseases  of  Females. 

1018.  The  first  evidence  of  the  placenta  being  over  the  mouth 
of  the  uterus,  may  declare  itself  so  early  as  between  the  sixth 
and  seventh  months  of  utero-gestation.  At  this  time,  the  neck 
of  the  uterus  begins  to  unfold  itself  for  the  more  complete  accom- 
modation of  the  foetus — in  consequence  of  which,  a  small  portion 
of  the  placenta  will  sometimes  be  separated  from  the  uterus; 
this  of  course  will  be  followed  by  a  discharge  of  blood,  commen- 
surate with  the  extent  of  the  lesion,  and  the  size  of  the  vessels 
involved  in  the  separation. 

1019.  This  discharge  may  sometimes  by  proper  management 
be  made  to  cease,  and  not  to  return  until  the  uterus  and  placenta 
are  again  forced  to  separate — then,  another  slight  hsemorrhage 
ensues,  which  may  also  cease ;  and  not  be  renewed  perhaps  until 
the  last  period  of  pregnancy;  or  there  may  be,  as  happens  some- 
times, a  constant  stillicidium  of  a  bloody  sanies  until  the  last  pe- 
riod of  gestation.  Dr.  Rigby,  who  is  considered  the  highest  au- 
thority upon  this  subject,  seems  not  to  have  bestowed  as  much 
attention  to  the  condition  of  the  patient  before  the  full  period  of 
utero-gestation,  as  he  did  to  the  consequences  after  that  time  had 
arrived,  or  he  would  not  have  held  the  doubtful  language  he  did 
when  speaking  of  the  "  time  and  manner"  in  which  the  "acci- 
dental" and  the  unavoidable  h&morrhage  came  on  ;  he  says 
^^ probably  that  which  is  occasioned  by  the  placenta  being  fixed  to 
the  OS  uteri,  will,  for  the  most  part,  not  come  on  till  the  full  term 
of  parturition,  when  the  uterus  begins  to  dilate  from  the  approach 
of  labour;  which  is  contrary  to  the  account  I  have  just  given, 
(1018,  1019,)  as  well  as  to  the  experience  of  almost  all  the  wri- 


UNAVOIDABLE  IliEMORRH AGE.  377 

ters*  upon  this  subject.  Besides,  the  very  economy  of  the  uterus 
makes  the  account  1  have  given  of  this  accident,  correct. 

1020.  It  must  not,  however,  be  supposed  I  insist,  that  the  wo- 
man will  necessarili/  be  subject  to  these  anticipating  discharges; 
I  only  wish  to  be  understood,  that  she  is  tmavoidabbj  liable  to 
them,  from  the  mechanism,  of  uterine  expansion.  The  oblitera- 
tion of  the  neck  of  the  uterus  is  not  purely  a  mechanical  operation; 
for  it  unquestionably  suffers  an  organic  developement  at  the  same 
time ;  and  much  will  depend,  as  regards  the  appearance  of  hae- 
morrhage before  the  full  period  of  utero-gestation,  whether  the  me- 
chanical or  physiological  process  shall  prevail.  Thus,  if  the 
neck  of  the  uterus  be  mechanically  operated  upon,  and  made  to 
yield  faster  than  the  organic  developement  can  follow,  a  portion 
of  the  placenta  will  be  detached,  and  a  discharge  of  blood  will 
follow.  When  this  takes  place,  the  orifice  of  the  uterus  will  be 
found  thinner  than  usual;  and  the  os  uteri  rather  more  open; 
and  this  happens  perhaps  more  frequently  than  otherways,  if  my 
observations  be  correct;  that  is,  I  have  witnessed  more  cases  of 
women  who  have  had  anticipating  discharges  of  blood,  than  those 
who  were  exempt  from  them. 

1021.  I  am  aware  this  does  not  correspond  with  the  cases  given 
us  by  Dr.  Rigby — agreeably  to  his  records,  nearly  two  to  one  had 
no  previous  discharge.  While  Baudelocque  tells  us,  that  the  dis- 
charge "sometimes  appears  as  early  as  the  sixth  month:  some- 
times not  until  the  ninth,  or  even  till  the  approach  of  labour;  but 
generally ,  from  the  seventh  to  the  eighth  month."  When  it  does 
not  appear  before  the  full  period  of  utero-gestation,  it  must  be 
owing  lo  the  growth  of  the  placenta  keeping  pace  with  the  or- 
ganic developement  of  the  neck  of  the  uterus;  or  in  other  words, 
where  the  mechanical  agency  is  inferior  to  the  physiological  coun- 
teraction. When  this  condition  obtains,  the  neck  of  the  uterus  is 
larger,  and  its  parietes  thicker  than  common;  indeed  it  has  been 
thought  by  Duparque,  that  it  is  not  entirely  developed  even  at 
full  time  under  such  circumstances,  and  that  it  is  on  this  account 
that  the  haemorrhage  does  not  appear  until  the  approach  of  la- 
bour. For  he  appears  to  believe  in  cases  of  the  implantation  of 
the  placenta  over  the  mouth  of  the  uterus,  that  the  neck  of  this 
organ  does  not  develope  itself  as  in  ordinary  cases  of  pregnancy; 
and  endeavours  to  prove  this,  by  saying,  he  opened  the  body  of 

*   See  Leroux,  Kok,  Baudelocque,  Denman,  Burns,  &.c. 
48 


378  UNAVOIDABLE  HiEMORRHAGE. 

a  woman  who  was  in  her  ninth  month;  the  neck  of  the  uterus  was 
very  thick,  and  projected  four  lines;  that  he  introduced  his  fin- 
ger with  difficulty  in  the  opening,  and  experienced  the  like  resist- 
ance when  he  attempted  to  pass  it  from  the  cavity  of  the  uterus 
outwards.  Now  this  proves  nothing  more,  than  in  that  case,  the 
developement  was  not  complete;  which  certainly  cannot  establish 
the  fact  he  wishes  to  prove,  namely,  that  in  all  cases  of  unavoid- 
able haemorrhages,  the  neck  of  the  uterus  is  less  expanded,  than 
when  the  placenta  is  attached  to  some  other  portion  of  this  organ 
than  the  neck.* 

1022.  It  is  not  difficult  to  believe,  that  the  neck  of  the  uterus 
in  the  cases  under  consideration,  is  found  sometimes  thicker  than 
it  ordinarily  is,  at  full  time;  because,  in  most  instances  of  pla- 
cental presentation,  we  believe,  that  haemorrhage  takes  place  be- 
fore the  exact  period  of  gestation  is  completed.  Our  reasons  for 
thinking  so,  are,  1st  That  in  common  cases,  which  arrive  to 
their  full  term,  but  where  the  placenta  is  attached  elsewhere 
than  to  the  mouth,  the  mouth  of  the  uterus  is  found  to  be  a  flat, 
plain  surface;  and  either  altogether  closed,  or  but  little  opened, 
and  the  edges  constituting  it,  thin.  2d,  Because,  this  species  of 
haemorrhage,  is  seldom  attended  with  pain  in  its  commencement; 
and  sometimes  not  at  all;  which  would  hardly  be  the  case,  were 
the  uterus  completely  developed ;  and  the  flooding  be  the  conse- 
quence of  an  entire  developement,  and  the  absolute  commence- 
ment of  labour. 

1023.  Therefore,  when  the  full  time  arrives,  the  woman  may 
be  surprised  by  a  sudden,  and  an  alarming  issue  of  blood,  without 
the  smallest  premonition — for  it  sometimes  makes  its  approach 
so  silently  and  so  rapidly,  that  the  patient  may  be  attacked  in 
the  midst  of  her  domestic  duties,  or  while  in  the  enjoyment  of 
company.  At  other  times  it  is  preceded  by  slight  and  distant 
pains ;t  and  when  this  is  the  case,  the  discharge,  for  the  most 

*  .Tourn.  Gen.  de  Med.  Vol.  29. 

j-  Wlien  this  species  of  flooding'  is  accompanied  by  pain,  it  will  in  general  be 
found  that  the  waste  is  neither  so  sudden  nor  so  profuse,  as  when  none  attends; 
though  each  contraction  of  the  uterus  augnncnts,  for  the  time  being-,  the  he- 
morrhage. It  must,  however,  be  observed,  tiiat  in  proportion  to  the  discharg-e, 
will  be,  (cseteris  paribus,)  the  diminution  of  the  uterine  force — and  hence  the 
infrequency  of  natural  deliveries  in  this  kind  of  flooding*.  Indeed  the  pain  seems 
almost  to  cease;  or,  in  other  words,  the  contractions  cease  almost  as  soon  as 
they  commence;  for  a  certain  fulness  of  blood  in  the  uterine  vessels,  seems 
essential  to  healthy  contraction. 


UNAVOIDABLE  HAEMORRHAGE.  379 

part  is  neither  so  sudden,  nor  so  alarmingly  extensive;  for  hse- 
morrliagc  is  never  so  overwhelming  nor  appalling,  as  when  the 
OS  uteri  siientl}^  and  rapidly  jaelds,  and  in  an  instant  exposes  a 
thousand  bleeding  vessels.* 

1024.  The  blood  flows  in  an  almost  unceasing  stream,  till  the 
woman  becomes  much  weakened  and  faint;  coagula  may  then 
form,  and  a  temporary  truce  ensue,  but  this  in  general  is  treach- 
erous, and  of  short  duration;  especially,  if  pains  attend;  for  the 
coagula  which  had  partially  arrested  the  haemorrhage  are  now 
driven  away  by  the  contractions  of  the  uterus,  or  by  the  opera- 
tion of  some  other  cause,  as  accidental  as  unavoidable,  and  the 
discharge  is  renewed  with  perhaps  even  increased  violence;  and 
in  this  way  may  things  proceed,  until  the  patient  is  either  ex- 
hausted by  the  waste  of  blood,  or  is  relieved  by  the  judicious  and 
successful  interposition  of  art. 

1025.  When  the  disciiarge  is  so  excessive  and  sudden  as  I  have 
just  described  it  to  he,  no  time  should  be  lost  before  it  is  ascer- 
tained whether  the  flooding  proceeds  from  a  separation  of  a  por- 
tion of  the  placenta  remotely  situated  from  the  os  uteri,  or  from 
this  mass  being  placed  over  it— the  symptoms  which  designate 
these  different  situations,  though  perhaps  pretty  strongly  marked, 
are  nevertheless  not  sufficiently  accurate,  to  render  a  more  certain 
and  decided  examination  unnecessary, 

102G.  We  should,  therefore,  upon  such  occasions,  always  exa- 
mine the  mouth  of  the  uterus  with  great  care.  In  conducting 
this,  the  finger  merely  introduced  into  the  vagina,  will  rarely  in- 
form us  with  sufficient  accuracy  ;  the  hand  should  be  conducted 
into  this  canal  that  the  utmost  freedom  may  be  given  to  this  im- 
portant examination.  A  proper  moment,  however,  should  be 
chosen  for  this  purpose,  that  no  evil  may  result  from  the  opera- 
tion ;  for  I  have  just  remarked,  that  a  suspension  of  the  discharge 
is  sometimes  eflfected  by  a  coagulum  within  the  vagina  or  mouth 
of  the  uterus,  which  being  removed  in  making  the  examination, 
may  renew  the  flooding;  while  the  blood  is  flowing  is  therefore 
the  time  to  make  this  attempt. 

1027.  When  the  hand  has  possession  of  the  vagina,  a  finger 

*  This  circumstance,  however,  rarely  obtains,  but  where  the  woman  has  ar- 
rived at,  or  very  near,  the  full  term,  and  where  she  has  been  teased  by  some 
previous  discharge.  May  not  the  pretty  constant,  though  inconsiderable  dis- 
charge just  noticed,  contribute  to  this  sudden  dilation  of  the  os  uteri,  by  acting 
as  a  uniform  local  depletion? 


380  UNAVOIDABLE  HEMORRHAGE. 

must  be  carried  within  the  os  uteri ;  it  should  then  carefully  and 
with  certainty,  determine  the  nature  of  the  substance  presented 
to  it ;  if  it  be  the  placenta  it  can  be  distinguished  from  a  coagu- 
lum,  (the  only  thing  to  which  it  has  any  resemblance,)  by  the 
following  characters:  1st,  The  placenta  always  presents  to  the 
touch  the  sensation  of  a  fibrous  structure  of  pretty  considerable 
firmness.  2d.  When  this  is  pressed  upon  by  the  extremity  of  the 
finger,  a  sensation  of  tearing  an  organized  mass  is  excited.  3d.  It 
being  much  firmer  in  its  consistence,  and  offering  more  resistance 
to  the  play  of  the  finger  within  it,  than  a  coagulum.  4th.  Its  not 
escaping  from  the  finger,  when  its  substance  is  in  some  measure 
broken  down  by  the  pressure  and  free  movement  of  it — it  can 
never  be  mistaken  for  the  membranes. 

1028.  In  a  case  of  such  importance,  we  should  neither  permit 
a  false  humanity,  nor  a  false  delicacy  to  get  the  better  of  an  im- 
perious duty;  for  upon  the  early  knowledge  of  the  species  of  flood- 
ing, the  woman's  life  may  unquestionably  depend.  We  should, 
therefore,  without  reserve,  state  to  the  friends  of  the  patient,  our 
opinion  of  the  nature  and  tendency  of  her  case,  and  the  import- 
ance of  ascertaining  it,  by  a  proper  examination.  This  will  al- 
most always  be  acquiesced  in;  and,  if  it  be  properly  conducted, 
it  will  neither  excite  severity  of  pain,  nor  wound  the  most  fasti- 
dious delicacy.  The  hand  for  the  most  part,  from  the  relaxation 
consequent  upon  a  continued  discharge,  will  pass  without  much 
difficulty;  or  it  may  be  made  to  do  so,  by  proper  lubrication. 

1029.  It  is  true,  indeed,  with  a  first  child,  and  at  an  incomplete 
period  of  utero-gestation,  there  may  be  some  difficulty  in  pass- 
ing the  hand,  if  the  discharge  has  not  been  pretty  abundant — 
but  in  this  case,  the  examinat  on  is  not  so  immediately  important; 
should  it,  however,  be  so,  from  the  excess  of  the  haemorrhage,  the 
parts  will  then  be  found  almost  always  sufficiently  yielding  to 
permit  the  passage  of  the  hand  without  much  difficulty.  The 
directions  just  given  for  ascertaining  the  particular  nature  of  the 
haemorrhage,  I  am  persuaded  should  never  be  neglected,  as  an 
attention  to  them  will  save  a  vast  expenditure  of  blood  in  all  cases, 
and  in  some  life  itself. 

1030.  Having  ascertained  it  to  be  a  placental  presentation,  the 
condition  of  the  mouth  of  the  uterus  should  next  be  carefully  ex- 
amined— the  degree  of  opening,  and  its  disposition  or  indisposi- 
tion to  dilate,  should  be  marked,  for  on  this  much  depends.  It 
will  be  found  in  one  of  the  following  situations:  1st,  but  little 


UNAVOIDABLE  ItiEMORRHAGE.  381 

opened  and  very  rigid;  2d,  but  little  opened,  yet  disposed  to  di- 
late; 3d,  opened  to  some  extent,  but  very  unyielding;  4th, 
opened  to  the  same  extent,  but  soft;  5th,  fully  dilated. 

1031.  The  nature  of  the  case  being  thus  ascertained,  the  mode 
of  treatment  is  next  to  be  considered.  This  will  necessarily  be 
much  influenced  by  the  particular  condition  of  the  woman,  and 
the  period  at  which  the  discharge  may  show  itself,  and  its  quan- 
tity make  interference  necessary.  1  have  already  noticed,  that 
when  the  placenta  is  situated  over  the  mouth  of  the  uterus,  slight 
discharges  of  blood  may  take  place  after  the  sixth  month,  as  a 
consequence  of  the  economy  of  the  uterus  (1018)  at  this  period; 
when  these  are  moderate,  they  may,  for  the  most  part,  be  arrest- 
ed by  the  means  usually  employed  for  flooding,  when  the  pla- 
centa is  not  placed  over  the  mouth  of  the  uterus ;  they  should 
therefore  be  put  into  immediate  requisition,  and  the  patient  placed 
under  the  strictest  injunctions  of  obedience,  and  conformity  to 
directions. 

1032.  For  a  discharge  of  blood  at  this  period  is  always  to  be 
looked  upon  as  liable  to  extreme  augmentation;  and  we  should 
never  lose  the  suspicion,  that  it  may  arise  from  the  peculiar  si- 
tuation of  the  placenta.  We  have  no  certain  means  by  which  the 
^'accidental"  may  at  this  time  be  distinguished  from  the  "una- 
voidable," unless  it  be  by  a  careful  examination — but  this  is 
never  necessary  so  long  as  the  flooding  is  moderate.  I  think 
however,  I  have  observed  in  the  "  unavoidable,"  that  the  flow  of 
blood  is  more  sudden  and  copious  in  a  given  time;  and  that  it  is 
more  fluid  and  florid  than  in  the  "accidental."  In  the  com- 
mencement, the  "unavoidable"  is  never  accompanied  by  coa- 
gula;  and  when  pain  attends,  the  discharge  is  always  increased 
at  each  contraction.  But  in  cases  demanding  precision,  these 
marks  cannot  be  relied  upon.  From  the  proximity  of  the  bleed- 
ing vessels  to  the  os  externum,  the  blood  will  issue  so  quickly 
from  them,  as  to  appear  both  more  fluid  and  more  florid,  than  in 
the  "accidental"  species;  for  in  the  "accidental,"  the  blood 
may  escape  remotely  from  the  os  uteri,  and  be  obliged  to  travel 
slowly  through  the  meshes  of  the  connecting  medium  oftlie  ovum 
and  uterus;  and  hence  will  appear  less  florid  and  fluid,  and  be 
more  disposed  to  coagulate  than  in  tlie  "unavoidable." 

1033.  But  coagula  will  form  in  the  "  unavoidable,"  when  the 
discharge  is  about  to  cease,  either  by  proper  treatment,  or  by  the 
mere  efforts  of  nature,  and  it  is  in  this  way  that  a  stop  is  put  to 
farther  waste. 


382  UNAVOIDABLE  HEMORRHAGE. 

1034.  As  we  cannot  determine  the  situation  of  the  placenta 
without  much  pain  and  force,  before  the  full  period,  when  the 
flooding  is  moderate,  it  may  always  be  well  to  treat  both  kinds 
as  if  they  were  cases  of  placental  presentations;  as  in  doing  so 
we  shall  be  erring  on  the  safe  side.  We  should  insist  upon  the 
most  perfect  tranquillity,  and  a  constant  confinement  to  the  hori- 
zontal position  whenever  practicable.  Blood  at  this  period  may 
be  taken  from  the  arm,  if  the  arterial  force  be  too  great;  cold 
applications  should  be  resorted  to;  and  the  sugar  of  lead  be  ex- 
hibited in  suificient  doses,  either  by  the  mouth  or  by  enemata 
as  already  advised.  Kok  and  others  recommend  cold  astringent 
injections  into  the  vagina:  of  the  utility  of  these  I  have  much 
doubt — at  least,  I  have  never  been  tempted  to  employ  them.  1 
rarely  pay  any  attention  to  the  state  of  the  bowels,  unless  they 
be  very  costive — then  a  mild,  warm  injection  of  molasses  and 
water,  or  soap  and  water,  will  be  every  way  sufficient.  I  am 
thoroughly  convinced  that  much  mischief  is  sometimes  done 
by  the  exhibition  of  even  the  very  mildest  purgatives;  and  the 
reason  will  be  immediately  obvious,  when  we  consider  the  ef- 
fects of  them,  I  have  frequently  permitted  my  patients,  under 
treatment  for  uterine  haemorrhage,  to  be  five  or  six  days  withuot 
a  discharge  from  the  bowels;  and  when  I  thought  it  necessary 
to  stir  them,  it  has  been,  for  the  most  part,  by  means  of  mild  in- 
jections. 

1035.  Kok  also  advises  the  introduction  of  some  substance, 
such  as  lint  or  rags,  into  the  vagina,  well  imbued  with  a  fluid 
styptic,  such  as  a  strong  solution  of  alum,  or  of  wine  in  which 
alum  is  dissolved.  I  should  place  more  reliance  upon  this  latter 
means  than  upon  the  former;  as  it  would  in  some  measure  act  as 
a  tampon,  and  serve  as  o.  point  cP apjnii  iov  coagula  to  form  upon ; 
for  at  last  we  must  have  these  form,  if  the  haimorrhage  stop  with 
out  having  done  much  mischief. 

1036.  I  have  advised  bleeding  when  the  pulse  is  active ;  Kok 
says,  this  is  useless,  if  not  injurious,  in  this  kind  of  flooding.  In 
this  I  cannot  agree  with  him;  and  for  the  following  reasons  : — 
1st.  Under  any  kind  of  active  haemorrhage,  when  the  pulse  is  vi- 
gorous, the  taking  away  blood  from  the  arm  has  uniformly  been 
found  useful,  by  producing  contraction  by  unloading  the  vessels 
t^D  a  certain  extent;  and  more  especially,  in  diminishing  the  ve- 
locity of  the  blood  within  them.     2dly.  As,  at  the  period  we  are 


UNAVOIDABLE  HEMORRHAGE.  383 

speaking  of,  we  cannot  decide  with  certainty  without  manifest  vio- 
lence, from  the  contingencies  just  mentioned,  that  the  discharge 
is  from  the  pecuhar  location  of  the  placenta,  we  may  act,  as  far  as 
the  bleeding  is  concerned,  as  if  it  were  an  "  accidental"  hoBmor- 
rhage;  especially,  as  the  blood  detracted  will  not  seriously  weak- 
en the  woman,  and  as  there  is  a  strong  probability  that  it  may 
be  arrested  until  the  last  period  of  pregnancy  by  proper  applica- 
tions and  treatment.  3dly.  That  at  this  period  the  haemon-hage 
is  for  the  most  part  owing  to  a  mechanical  separation  of  a  portion 
of  the  placenta;  but  which  will  not  generally  be  renewed  for 
some  time,  as  the  separated  vessels,  and  the  other  connecting  me- 
dia, possess  considerable  elasticity;  therefore,  time  will  be  given 
for  the  formation  of  coagula,  provided  the  proper  means  be  pur- 
sued to  favour  their  production;  among  which  we  must  reckon 
bleeding.  4thly.  If  the  discharge  be  not  produced  by  external 
violence,  or  any  other  cause  which  will  certainly  excite  the  action 
of  the  uterus,  there  is  a  strong  probability,  that  it  will  cease  for 
the  time  being;  unless  it  be  improperly  treated,  or  unnecessarily 
provoked. 

1037.  Should  the  body  and  fundus  of  the  uterus  be  excited  into 
action  from  any  cause,  at  this  period;  and  the  discharge  be  rather 
the  eflect  of  such  contractions,  than  the  natural  and  unavoidable 
stretching  of  the  neck  of  this  organ,  we  have  great  reason  to  fear, 
that  we  shall  not  be  able  to  suspend  these  efforts,  so  as  to  enable 
the  woman  to  go  the  full  term  of  gestation.  But  should  we  ever 
have  this  intention  in  view,  as  it  may  sometimes  be  happily  ful- 
fdled;  and  if  it  be  not,  it  is  decidedly  the  most  proper  mode  of 
treating  the  complaint. 

1038.  In  such  cases,  vve  should  endeavour  as  quickly  as  pos- 
sible to  interrupt  uterine  contraction  ;  for  this  purpose,  we  should 
bleed  under  the  restrictions  just  mentioned;  we  should  exhibit 
the  sugar  of  lead  with  laudanum,  as  frequently  as  the  exigencies 
of  the  case  may  require;  and  by  enemata,  I  thmk,  is  much  the 
most  prompt  and  eiFicacious  mode  of  administering  them.  From 
a  scruple  to  half  a  drachm  of  this  salt,  with  a  drachm  of  lauda- 
num, and  a  gill  of  water,  may  be  thrown  up  the  rectum  every 
hour,  or  more  seldom,  as  occasion  may  call  for  them.  All  the 
auxiliary  plans  I  have  already  recommended  should  be  put  in  re- 
quisition, and  their  full  adoption  rigidily  enforced. 

1039.  Should  these  means  moderate  the  discharge,  and  the 
blood  be  found  disposed  to  coagulate;  and  if  at  the  same  time 


384  UNAVOIDABLE  HJEMORRHAGE. 

uterine  contractions  have  ceased,  or  even  considerably  diminished, 
we  may  be  encouraged  to  persevere  in  the  use  of  these  remedies, 
and  entertain  an  expectation  of  uhimate  success.  The  intro- 
duction of  a  moderate  sized  tampon  of  sponge  at  this  time,  as 
a  mevejwint  d'appui,  is  highly  useful;  for,  without  some  such 
support,  the  coagulamay  be  discharged,  and  the  haemorrhage 
renewed. 

1040.  The  artificial  support  for  coagula,  which  I  have  recom- 
mended above,  (1039)  is  of  more  consequence  than  we  would  at 
finst  imagine.  It  permits  the  thinner  parts  of  the  blood  to  escape 
through  the  meshes  of  the  sponge,  by  which  means  the  coagula 
are  rendered  more  firm  and  tenacious;  besides  diminishing,  by  a 
counter  action,  the  influence  of  the  vis  a  tergo,  which  is  con- 
stantly operating  to  throw  them  off. 

1041.  I  am  aware,  that  some  rely  upon  the  coagula  without  the 
tampon;  and  I  must  admit,  that  they  have  occasionally  been 
sufficient  to  save  the  woman's  life;  a  case  of  this  kind,  is  related 
by  Leroux;*  but  he  expressly  declai-es  they  are  not  to  be  relied 
upon.  The  sudden  movement  of  the  woman's  body,  for  even 
necessary  purposes;  uterine  contraction;  the  escape  of  the  wa- 
ters, &c.  may  all  serve  to  disturb  the  coagulum  which  has  arrest- 
ed the  hemorrhage.  But  the  most  important  use  of  the  tampon 
under  these  circumstances,  remains  to  be  mentioned  ;  which  is, 
that  it  causes  the  coagulation  of  the  blood,  merely  by  presenting 
a  surface  favourable  to  this  change,  long  before  this  disposition 
would  spontaneously  show  itself;  for  in  general,  this  effect  is  not 
produced,  but  when  the  woman  is  much  exhausted,  or  by  the  ra- 
ther tardy,  though  successful  influence,  or  the  remedies  previously 
employed. t 

1042.  Should  our  endeavours,  however,  fail  to  arrest  the  dis- 
charge, we  should,  without  farther  loss  of  time,  ascertain  the  con- 
dition of  the  OS  uteri,  and  then  j^roceed  precisely  as  if  the  woman 
had  arrived  at  her  full  time  when  the  haemorrhage  commenced  ; 
for  it  will  now  be  found  that  the  cases  are  reduced  exactly  to  the 
same  condition,  and  will  require  the  same  niode  of  management; 
of  which  I  shall  speak  more  at  large  presently. 

1043.  A  woman  may  escape  these  anticipating  discharges  un- 
til she  complete  her  full  term;  but  at  this  time  it, will  be  seen  that 

*  Observations,  p.  258. 

f  Mr.  Burns  assures  us,  he  never  saw  a  case  which  required  delivery  during 
the  first  paroxysm,  if  a  proper  treatment  had  been  adopted. — {Principles  of 
Midwifery,  5th.  ed.  p.  323.) 


UNAVOIDABLE  HAEMORRHAGE.  385 

the  uterus  cannot  expel  its  contents  without  necessarily  exposing 
the  patient  to  the  most  imminent  risk.  So  alarmingly  profuse^ 
and  so  decidedly  dangerous  are  these  discharges  in  some  instances' 
that  a  few  minutes  are  sufficient  to  exhaust  the  strength,  or  to 
deprive  the  woman  of  life. 

1044.  I  once  witnessed  a  case  in  which  there  was  discharged 
from  the  uterus,  in  the  course  of  about  fifteen  minutes,  a  full  half 
gallon  of  blood;  and  was  sent  for  in  another  instance,  where  the 
woman  had  expired  before  my  arrival,  though  there  had  not,  as 
the  midwife  assured  me,  more  than  half  an  hour  passed  from  the 
commencement  of  the  flooding  to  its  fatal  termination.  These 
are,  however,  extreme  cases ;  yet  they  show  how  suddenly  and 
certainly,  they  may  be  fatal.  It  is  confessed,  on  all  hands,  that 
no  accident  attendant  upon  conception  is  equally  menacing  as  the 
unavoidable  hasmorrhage;  and  it  also  emphatically  declares  to 
the  physician,  that  much  depends  upon  him  that  it  shall  not  be 
very  often  fatal.  It  is  one  of  those  extraordinary  cases,  in  which 
nature  does  less  for  the  preservation  of  the  individual,  than  almost 
any  other. 

1045.  This  does  not  arise  so  much  from  want  of  exertion  on 
the  part  of  nature,  if  I  may  so  term  it,  as  from  the  almost  entire 
incompatibility  of  giving  birth  to  the  child,  and  protecting  the 
woman  against  flooding,  at  one  and  the  same  time.  Yet  we  learn, 
from  such  authority  as  cannot  be  doubted,  that  the  woman,  left 
entirely  to  herself,  vvill  not  always  perish.  The  means,  however, 
which  nature  employs  to  procure  this  immunity  offer  neither  a 
useful  practical  hint,  nor  the  smallest  inducement  to  imitate  her; 
for  they  are  so  entirely  contingent,  and  sometimes  so  long  with- 
held, that  the  woman  from  her  great  exhaustion,  can  scarcely  be 
said  to  profit  by  the  interposition. 

1046.  Baudelocque*  says,  the  woman  may  be  preserved  ''  when 
the  orifice  is  fully  dilated,  and  the  mass  separate  entirely  from  it, 
and  be  so  far  removed  from  one  side,  that  the  membranes  may  pre- 
sent. The  membranes  may  then  tear  spontaneously,  and  delivery 
be  performed  naturally,  if  the  woman,  notwithstanding  her  loss 
of  blood,  still  preserves  sufficient  strength,  as  has  sometimes  hap- 
pened." Leroux,t  by  the  formation  of  coagula,  and  the  sponta- 
neous action  of  the  uterus.      Smellie,^  to  the  entire  separation  of 

*  System  of  Midwifery,  Vol.  II.  par.  986. 
\  Observations,  &c.  p.  306. 

\  Midwifery,  Vol.  II.  Col.  18,  No.  3.  Cases,  No.  3,  4,  5,  6,  7. 
49 


386  UNAVOIDABLE  H-EMOKRHAGE. 

the  placenta,  rupture  of  the  membranes,  and  the  placenta  being 
first  delivered,  &c,  &c. 

1047.  From  this  it  would  appear  that  in  some  rare  instances 
the  woman  has  been  saved  by  the  natural  agents  efiecting  the 
delivery  before  she  vvas  too  much  exhausted;  but  we  do  not  pro- 
fit by  the  knowledge  of  the  manner  in  which  this  was  performed. 
It  is  therefore,  now  completely  established,  that  the  only  chance 
the  woman  has  for  life,  is  by  a  u^ell-timed  and  well-conducted 
delivery  in  every  case,  (cseteris  2Juribus,j  of  placental  presenta- 
tion. 

1048.  Though  it  be  universally  admitted  that  there  is  but  one 
mode  of  proceeding  in  the  case  we  are  now  considering;  yet  it 
is  not  so  generally  conceded  that  the  success  of  that  mode  es- 
sentially requires  that  the  delivery  be  properly  timed,  and  as  pro- 
perly conducted.  All  who  have  written  upon  this  subject,  seem 
to  agree  in  one  of  the  positions;  namely,  that  delivery  is  abso- 
lutely necessary;  but  many,  and  indeed  I  may  add  too  many, 
have  been  regardless  of  the  conditions  which  serve  to  render  this 
operation  availing. 

1049.  The  success  of  the  operation  of  turning  for  the  relief  of 
this  species  of  haemorrhage,  must  depend  upon  its  being  perform- 
ed under  the  proper  conditions  of  the  mouth  of  the  uterus.  We 
have  already  insisted  on  this  when  treating  of  "  turning,"  there- 
fore shall  not  repeat  here  the  rules  we  laid  down  as  essential  to 
success,  whenever  this  operation  is  performed. 

1050.  The  time  when  we  shall  attempt  delivery  is  of  the 
greatest  moment,  and  deserves  particular  investigation.  Dr.  Den- 
man  says,  "  it  would  be  of  great  advantage  in  practice,  if  some 
mark  were  discovered,  or  some  symptom  observed,  which  would 
indicate  the  precise  time  when  women  with  hasmorrhagesof  this 
kind  ought  to  be  delivered;"  but  declares,  "we  do  not  at  present 
know  any  such  mark."  Yet  almost  immediately  after  decides, 
that  "  whenever  the  case  dem.ands  the  operation,  on  account  of 
the  danger  of  the  hasmorrhage,  the  state  of  the  parts  will  on  this 
account  always  allow  it  to  be  performed  with  safety,  though  not 
with  equal  facility." 

1051.  If  this  be  true,  we  are  certainly  in  possession  of  what 
Dr.  D.  thought  so  great  a  desideratum — for  if  the  parts  be  in 
condition  to  turn  with  safety,  it  is  certainly  all  that  is  required, 
when  "  the  danger  of  the  haemorrhage  demands  the  operation." 
For  if  the  parts  permit  turning  without  risk,  they  must  be  in  a 


UNAVOIDABLE  HAEMORRHAGE.  387 

dilated  or  a  dilatable  state,  and  tliis  is  all  that  is,  or  can  be  re- 
quired when  the  condition  of  the  flooding  "  demands  the  opera- 
tion." Then  we  have  a  rule  which  is  never  failing,  when  this 
condition  of  the  parts  obtains,  if  it  be  true  that  this  can  always 
be  done  with  safety,  if  not  with  equal  facility. 

1052.  Now,  it  is  of  importance  to  inquire  whether  turning  can 
always  be  performed  with  safety  when  the  parts  are  in  a  condi- 
tion to  permit  it;  for  upon  this  much  depends.  It  would  seem, 
agreeably  to  this  position,  that  the  whole  risk  the  woman  runs  in 
these  cases,  arises  from  the  "  state  of  the  parts,"  opposing  the  in- 
troduction of  the  hand;  and  when  they  do  not,  that  turning  may 
then  be  performed  with  safety — experience,  however,  constant- 
ly contradicts  this  unqualified  opinion,  for  the  woman  may  be  so 
far  reduced  that  she  may  expire  before  the  operation  is  com- 
pleted, or  very  quickly  after.* 

1053.  Besides,  the  manner  in  which  we  find  the  opinion  slated 
by  Dr.  D.  would  lead  to  the  persuasion,  that  so  long  as  the  os  uteri 
was  not  opened,  there  could  be  no  danger,  whatever  might  be  the 
quantity  discharged,  than  which  nothing  can  be  more  unfounded. 
For  it  is  a  well-known  fact,  that  the  powers  of  the  uterus  may  be 
so  far  impaired  as  not  to  perform  this  office,  even  at  the  last  mo- 
ment of  existence.  In  this  I  am  supported  by  Rigby,t  who  de- 
clares, that  were  "  this  rule  invariably  adhered  to,  in  some  cases, 
it  would  be  attended  with  danger,  as  we  might  wait  for  the  open- 
ing of  the  uterus  till  it  was  too  late  to  relieve  the  woman  by  turn- 
ing the  child." 

1054.  This  will  be  very  readily  understood,  when  it  is  recol- 
lected, that  the  opening  of  the  uterus  mainly  depends  upon  the 
longitudinal  fibres  acquiring  the  mastery  of  the  circular;  but  when 
the  uterus  is  so  far  exhausted  of  contractile  power  as  to  remain 
passive,  or  nearly  so,  we  shall  always  find  the  os  uteri  closed,  (un- 
less previously  distended  by  an  exertion  of  its  powers,)  though  it 
may  be  most  easily  dilutable.  I  may  perhaps  even  acquiesce  in 
the  explanation  of  Dr.  RigbyJ  upon  this  subject,  who  supposes 

*  of  tliis  we  have  ample  proof,  in  cases  58,  81,  82,  89,  98,  &c,  of  Rig-by,  in 
each  of  which  the  condition  of  the  parts  easily  permitted  turning,  but  not  with 
safety.  But  I  am  cleai-ly  to  be  understood  that  I  attach  no  censure  to  the  ope- 
ration; for  I  am  of  opinion  it  was  the  only  thing  that  coidd  be  done  to  give  the 
woman  a  chance — and  I  liave  no  doubt,  it  was  properly  performed.  But  these 
cases  goto  prove  the  incorrectness  of  tlie  position  I  am  now  examining. 

f  Essay,  6th  ed.  p.  40. 

i:  Essay,  6th  cd.  p.  40. 


388  UNAVOIDABLE  HEMORRHAGE. 

that  the  position  of  the  placenta  may  serve  to  keep  the  uterus 
closed,  by  surrounding  its  mouth,  by  the  attachment  of  its  fibres 
to  this  part,  which  is  now  perfectly  passive  and  unresisting — this 
is  both  ingenious  and  probable. 

1055.  I  must  now  make  a  distinction  of  great  practical  import- 
ance, that  has  never,  ^o  far  as  I  know,  been  pointed  out;  which, 
if  it  be  just,  (and  my  experience  gives  me  every  reason  to  believe 
it  is,)  will  in  some  measure  serve  to  reconcile  the  conflicting  opin- 
ions of  writers  upon  the  subject  of  the  time  when  it  would  be 
invariably  proper  to  attempt  the  relief  of  the  patient  by  turning — 
it  is  simply  this,  that  there  is  a  most  material  difierence  between 
the  dilatation  of  the  os  uteri,  or  even  its  dilatability,  when  efiected 
by  the  natural  povv^ers  of  this  organ,  and  that  passive  or  quiescent 
condition,  which  results  from  the  langour  of  death. 

1056.  Tiie  one  is  the  result  of  its  organization,  when  its  powers 
are  not  too  much  impaired  or  prostrated  by  disease;  while  the 
other  is  a  syncope,  if  I  may  so  term  it,  produced,  when  these 
powers  are  exhausted  by  an  excessive  waste  of  blood.  This  dis- 
tinction must  constantly  be  kept  in  view;  for  on  it  depends  the 
rational  mode  of  treating  this  formidable  complaint:  for  if  it  be  not, 
we  prescribe  both  uncertainly  and  empirically.  An  attention  to  the 
one,  leads  us  to  husband  with  the  utmost  care  the  strength  and 
vigour  of  the  patient;  while  the  other  makes  us  regardless,  if  not 
prodigal  of  it;  the  one  is  almost  always  crowned  by  success;  the 
other  leads  almost  constantly  to  a  doubtful  issue. 

1057.  We  can  readily  account,  with  this  distinction  in  view, 
for  the  difference  of  success  in  the  operation  of  turning.  When 
performed  after  the  dilatation  of  the  uterus  has  been  effected  by 
the  natural  agents,  it  has  perhaps  almost  always  been  attended 
by  the  much  desired  issue;  but  when  performed  after  the  flacci- 
dity  of  approaching  death  had  ceased  to  make  it  difficult,  it  too 
often  has  been  followed  by  the  loss  of  the  patient.  Under  this 
impression,  I  should  say,  that  when  the  os  uteri  was  either  dilated 
or  rendered  dilatable  by  the  operations  of  this  organ;  and  before 
the  strength  of  the  patient  was  materially  impaired,  that  then, 
and  then  only,  was  the  desirable  time  to  operate ;  but  if  circum- 
stances prevent  advantage  being  taken  of  the  proper  moment, 
and  nothing  but  a  choice  of  difficulties  remain,  we  should  cer- 
tainly attempt  to  snatch  the  woman  from  her  impending  fate;  but 
this  should  be  under  the  cautions  already  suggested. 

1058.  1  will  attempt  to  put  this  subject  in  a  clearer  point  of 


UNAVOIDABLE  II.T.:\rORKHAGE.  389 

view,  by  considering  what  ought  to  be  attempted  for  the  relief  of 
the  patient  under  each  of  the  conditions  of  the  uterus  pointed  out 
above;  (1030)  and  which  necessarily  comprehends  every  state  of 
which  it  is  at  this  time  susceptible. 

Sect.  I. — 1.  TF/iere  the  Uterus  is  but  little  opened,  and  is  very 
rigid. 

1059.  In  the  condition  of  the  uterus  here  designated,  all  the 
evils  which  can  attend  the  forcing  of  a  rigid  os  uteri,  would  take 
place  by  an  attempt  to  deliver;  it  should  therefore  not  be  thought 
of  Indeed,  this  has  ever  been  a  subject  of  great  embarrassment 
to  writers  upon  this  subject;  and  makes  them  in  many  instances 
at  variance  with  themselves;  or  they  give  their  directions  so  ob- 
scurely, and  so  hesitatingly  as  to  confound  the  judgment  of  the 
young  practitioner.*  It  has  given  rise  to  two  modes  of  proceed- 
ing, each  of  which  is  equally  wrong. 

1060.  The  first  is  to  force  the  uterus,  however  rigid,  provided 
a  finger  can  be  introduced.  I  have  already  said  much  upon  this 
plan,  and  shall  only  add  in  proof  of  it  a  quotation  from  Dr.  Rigbyt 
everyway  illustrative  of  the  impropriety  of  this  outrageous  prac- 
tice. J  "In  recommending  early  delivery,  I  think  it  right,  how- 
ever, to  express  a  caution  against  the  premature  introduction  of 
the  hand,  and  the  too  forcible  dilatation  of  the  os  uteri,  before  it 
is  sufficiently  relaxed  by  pain  or  discharge,  for  it  is  undoubtedly 
very  certain  that  the  turning  may  be  performed  too  soon,  as  well 
as  too  late,  and  that  the  consequences  of  the  one  may  be  as  de- 
structive to  the  patient  as  the  other.  I  am  particularly  led  to 
observe  this,  as  I  have  lately  been  informed  from  very  good  autho- 
rity, (namely,  a  gentleman  to  whom  one  of  the  cases  occurred,) 

*  For  an  instance  of  this  kind,  I  may  cite  even  Mr,  Burns  himself — he  tells 
us,  in  one  sentence,  "if  the  hremorrhage  have  been  or  continues  to  be  consider- 
able, we  must  not  wait  until  tlie  os  uteri  be  much  dilated,  as  we  tlius  reduce 
the  woman  to  great  danger,  and  diminish  the  chance  of  recovery."  A  few  lines 
farther  in  the  same  page,  he  says  "  a  prudent  practitioner  will  not  violently  open 
up  the  OS  utei-i,  but  will  use  the  plug.''-  A  little  further  on,  he  declares,  "he, 
(a  prudent  practitioner,)  will  not  allow  his  patient  to  lose  much  blood,  or  have 
many  attacks;  he  will  deliver  her  immediately,  for  we  know  that  whenever 
that  is  necessary,  that  it  is  easy,  the  os  uteri  yielding  to  his  cautious  endea- 
vours."— (Princip.  5th.  ed.  p.  324.) 

f  Essay  on  Uterine  Hemorrhage,  5th  ed.  p.  40. 

+  See  Chapters  "  On  the  causes,  which  may  render  anatural,  a  preternatural 
Labour^"  and  "onTui'ning." 


390  UNAVOIDABLE  HEMORRHAGE. 

of  three  unhappy  instances  of  an  error  of  this  sort,  which  hap- 
pened some  years  ago  to  three  surgeons  of  estabhshed  reputation, 
who,  from  the  success  they  had  met  with  in  deHvering  several 
who  were  reduced  to  the  last  extremity,  were  encouraged  to  at- 
tempt it  where  but  very  little  blood  had  been  lost,  in  hopes  that 
their  patients'  constitutions  would  suffer  less  injury,  and  their  re- 
covery be  more  speedy;  which,  till  the  experiment  was  made,  was 
a  very  reasonable  supposition — the  women  died,  and  they  seemed 
convinced  that  their  deaths  were  owing  to  the  violence  of  being 
delivered  too  soon,  and  not  to  the  loss  of  blood,  or  any  other 
cause." 

1061.  The  other  is,  to  permit  the  flooding  to  proceed  until  the 
woman  shall  be  so  much  exhausted  as  to  render  the  uterus  pliant. 
Dr.  Denman,  as  I  have  just  noticed,  supposed  that  when  danger 
created  a  necessity  for  delivery,  that  then,  from  the  loss  of 
blood,  the  uterus  would  permit  it  with  safety.  Dr.  Rigby  says, 
that  when  the  uterus  contracts  firmly  round  the  fingers,  we 
should  desist  from  any  attempt  to  deliver,  and  wait  till  the  part 
be  more  relaxed  by  pain  or  discharge;  and  adds,  "as  an  encou- 
ragement, that  we  may  safely  suffer  a  woman  to  lose  more  blood, 
the  contraction  may  certainly  be  looked  upon  as  a  proof  that 
there  still  remains  a  considerable  portion  of  animal  strength,  and 
that  she  has  not  been  so  much  affected  by  the  loss  as  we  before 
imagined." 

1062.  I  cannot  recommend  this  plan,  though  it  be  the  advice 
of  the  first  authority  upon  this  subject.  I  am  convinced,  from 
both  reason  and  experience,  that  it  is  seldom  or  never  necessary; 
and  is  perhaps  always  injurious.  To  save  the  woman  an  ounce 
of  blood,  is  a  duty:  to  save  her  forty,  or  perhaps  much  more,  is 
still  a  greater  one.  To  follow,  then,  the  speculation  of  Dr.  Den- 
man, or  the  advice  of  Dr.  Rigby,  would  be  widely  departing  from 
these  duties.     1  do  not,  I  cannot  adopt  either. 

1063.  What  is  essentially  important  to  be  done  in  this  case? 
1st.  To  save  as  much  and  as  quickly  as  we  can,  the  farther  ex- 
penditure'of  blood.  2d.  To  obtain,  as  soon  as  the  natural  powers 
will  effect  it,  the  dilatation  or  dilatability  of  the  uterus.  3d.  To 
deliver  then  with  as  much  speed  as  is  consistent  with  the  welfare 
of  both  mother  and  child. 

1064.  The  first  and  second  of  these  indications  are,  as  far  as  I 
have  witnessed  for  the  last  thirty  years,  readily  complied  with  b}^ 
ihe  use  of  the  tampon,  and  the  other  auxiliary  remedies.     If  they 


UNAVOIDiVBLE    HiEMORRHAGE.  391 

be  instantly  had  recourse  to,  the  discharge  will  almost  immedi- 
ately abate;  or  in  a  short  time  be  so  diminished  as  to  give  no 
immediate  concern.  By  this  means  we  not  only  staunch  the  hae- 
morrhage, but  gain  most  important  time;  for  during  this  truce, 
the  natural  agents  of  delivery  will  effect  the  desired  relaxation  of 
the  OS  uteri. 

1065.  This  plan,  I  believe,  originated  with  Leroux;  and  has 
been  adopted  with  entire  success  by  myself  for  many  years  past. 
It  has  also  the  sanction  of  Mr.  John  Burns,  who  recommends  it 
by  saying,  "a  prudent  practitioner  will  not  violently  open  the  os 
uteri  at  an  early  period,  but  will  use  the  plug,  until  the  os  uteri 
become  soft  and  dilatable."  It  is  true,  Gardien  thinks  the  plug 
will  do  harm,  by  exciting  the  uterus,  and  thus  increase  the  sepa- 
ration of  the  placenta — but  this  is  theory;  it  is  not  consonant 
with  experience. 

1066.  The  following  case,  selected  from  several  of  a  similar 
kind,  will  place  in  a  clear  point  of  view  the  promptness  and  effi- 
cacy of  this  plan.     Mrs. ,  while  looking  out  of  her  window, 

was  suddenly  surprised  by  a  profuse  discharge  of  blood  from  the 
vagina.  Before  I  arrived,  though  near  at  hand,  more  than  half 
a  gallon  of  blood  was  expended  upon  the  floor  and  in  a  pot.  The 
patient  was  upon  the  bed,  pale,  feeble,  and  excessively  alarmed. 
I  examined  her  immediately,  and  found  the  uterus  rigid,  and  the 
placenta  presenting.  She  had  no  pain;  nor  had  she  any,  previous 
to  the  irruption  of  blood.  The  discharge  was  very  profuse  and 
exhausting;  but  as  the  os  uteri  was  undilated,  and  rigid,  I  intro- 
duced the  tampon,  and  secured  it  within  the  vagina  by  a  com- 
press upon  the  external  labia  with  a  T-bandage.  The  flooding 
ceased  immediately,  and  there  was  nothing  passed  the  os  exter- 
num but  some  of  the  thinner  parts  of  the  blood.  After  the  tam- 
pon had  been  applied  about  four  hours,  pains  commenced  pretty 
briskly,  and  in  about  two  hours  more,  they  were  of  considerable 
force,  so  much  so  as  to  press  against  the  external  compress  with 
some  violence.  I  now  removed  the  tampon;  and  the  os  uteri  was 
found  sufficiently  dilated  to  allow  the  hand  to  pass  with  entire 
freedom;  and  the  delivery  was  quickly  efiected,  with  safety  to 
both  mother  and  child. 

1067.  For  the  successful  fulfdment  of  the  third,  and  last  indi- 
cation, it  is  necessary  that  the  jiractitioner  should  be  well  ac- 
quainted with  the  condition  of  the  uterus,  at  the  moment  he  is 
about  to  commence  the  operation;  that  is,  he  should  know  how 


392  UNAVOIDABLE  HiEMORRHAGE. 

far  he  may  rely  upon  its  co-operation,  or  how  far  it  may  be  capa- 
ble of  that  degree  of  contraction  which  shall  secure  the  woman 
against  a  farther  loss  of  blood.  This  can  only  be  presumed,  from 
taking  into  view  the  quantity  of  blood  lost;  the  debility  or  ex- 
haustion it  has  occasioned ;  and  the  degree  of  force  the  uterus  may 
exert,  at  each  return  "of  pain. 

1068.  If  it  be  found,  that  the  quantity  of  blood  is  not  excessive; 
if  the  degree  of  exhaustion  be  not  alarming;  and  if,  above  all, 
the  uterus  manifest  considerable  vigour;  the  delivery  may  be  ac- 
complished in  much  shorter  time,  and  with  much  greater  promise 
of  success,  (especiaUy  to  the  child,)  than  if  the  contrary  of  these 
obtain — in  the  latter  case,  the  delivery  must  be  conducted  with 
the  utmost  caution,  that  the  uterus  may  noi  be  too  suddenly  emp- 
tied, and  augment  the  danger  to  both  mother  and  child.  I  shall 
again  advert  to  this  subject,  when  I  come  to  describe  the  manner 
of  conducting  the  operation  of  turning,  or  effecting  the  delivery  in 
such  cases. 

Sect.  II. — 2.    When  but  little  opened,  but  disposed  to  dilate. 

1069.  In  this  situation  of  the  uterus,  but  few  obstacles  to  turn- 
ing or  delivery  will  present  themselves;  since,  if  the  necessity  of 
the  case  require  the  operation,  the  great  objection  to  it  is  in  some 
measure  removed;  for  this  disposition  to  yield  to  a  moderate 
force,  will  secure  the  woman  against  an  excessive  loss  of  blood, 
by  taking  advantage  of  it,  and  effecting  the  delivery  in  proper 
time. 

1070.  But  it  must  be  recollected,  that  though  the  uterus  may 
be  disposed  to  yield,  with  even  a  moderate  force,  to  a  certain  ex- 
tent, if  it  be  slowly  and  judiciously  applied,  yet  it  ma}^  refuse  to 
relax  beyond  this,  or  to  such  a  degree  as  would  not  embarrass  the 
operation;  nor  can  it  sometimes  be  made  to  yield  more,  unless  a 
dangerous  or  reprehensible  force  be  applied.* 

1071.  In  a  case  of  this  kind,  we  should  gain  time  by  the  em- 
ployment of  the  tampon,  as  directed  above,  and  not  subject  the 
woman  to  unnecessary  risk,  by  attempting  to  overcome  the  re- 
sistance of  the  uterus  by  violence;  and  it  must  also  be  recollected, 
that,  in  cases  like  these;  cases  so  replete  with  risk,  we  are  to 
devote  ourselves  to  the  best  interests  of  our  patients — they  should 
never  be  subjected  to  the  chance  of  a  fatal  haemorrhage,  by  our 

'"  Leroiix,  Mariceau,  Rigby,  &.c. 


UNAVOIDABLE  HAEMORRHAGE.  393 

leaving  them  even  for  a  short  time;  for  neither  the  plea  of  other 
engagements,  nor  a  persuasion  tliey  can  receive  no  injury  during 
a  short  interval  of  absence,  can  justify  our  withdrawing  ourselves 
from  them;  I  could  cite  a  number  of  instances  in  support  of  this, 
were  such  confirmation  necessary.  If  it  be  judged  proper  to  em- 
ploy the  tampon,  we  should  wait  patiently  for  its  effects;  but  we 
should  wait  at  the  bedside^  or  near  the  patient  that  we  may  take 
immediate  advantage  of  any  favourable  change  in  the  condition 
of  the  parts,  for  which  we  were  so  anxiously  looking;  or  guard 
against  any  unfavourable  contingency,  that  might  suddenly  or  un- 
expectedly arise. 

1072.  Sometimes,  indeed,  the  os  uteri  appears  entirely  closed, 
though  at  the  same  time  it  is  easily  dilatable;  this  case  should  not 
be  confounded  with  the  one  just  considered:  for  here  the  woman 
may  be  readily  delivered,  as  far  as  the  condition  of  the  mouth  of 
the  uterus  is  concerned,  should  the  urgency  of  the  case  require  it. 
This  situation  of  the  uterus,  for  the  most  part,  only  takes  place 
when  the  woman  is  nearly  exhausted,  and  its  powers  so  far  im- 
paired, that  the  agents  for  the  absolute  dilatation  of  its  orifice 
are  incapable  of  the  efibrt.  Should  we  wait  for  the  expansion  of 
the  OS  uteri  in  such  instances,  we  should  wait  in  vain;  and  per- 
haps even  be  made  witnesses  of  the  death  of  the  patient.* 

Sect.  III. — 3.  Opened  to  some  extent,  but  very  unyielding. 

1073.  Were  we  to  consult  authors  upon  the  point  of  practice 
in  this  condition  of  the  uterus,  we  should  find  too  m.any  sanc- 
tioning forced  delivery.  I  might  employ  the  arguments  here, 
that  I  have  already  used  against  any  violence  being  committed 
upon  an  unyielding  uterus;  for  it  may  sustain  as  much  injury  in 
the  condition  supposed  here,  as  in  the  instances  I  have  been  con- 
sidering; for  if  the  opening  be  insufficient  to  permit  the  hand  to 
pass  without  the  employment  of  force,  it  will  certainly  be  insuffi- 
cient to  allow  the  foetus  to  pass  without  using  much  more;  it 
should,  therefore,  be  considered  full  as  ineligible  to  operate  in  this 
case,  as  in  the  two  I  have  just  noticed. 

1074.  Besides,  there  is  less  excuse  for  being  precipitate  in  this 
case;  since,  the  desired  relaxation  will  most  probably  soon  ensue, 
as  the  OS  uteri  has  already  yielded  to  some  extent;  therefore,  by 
giving  it  a  little  more  time;  and  by  employing  the  tampon,  the 
delivery  may  be  accomplished  without  either  violence  or  risk. 

*   See  llig-by  on  Uterine  Hemorrhage. 
50 


394  UNAVOIDABLE    HEMORRHAGE. 

1075.  Had  we  no  command  of  the  hsemorrhage,  we  perhaps 
might  be  justified  in  the  employment  of  force;  as  it  would  then 
be  a  dernier  resource;  but  as  we  can  certainly  control  the  dis- 
charge by  the  tampon,  we  should  be  inexcusable  to  attempt  de- 
livery, until  it  has  been  properly  tried,  and  it  had  failed. 

1076.  But  let  not  this  case  be  confounded  with  the  condition 
next  to  be  mentioned.  For  when  it  is  ascertained  that  the  ute- 
rus though  opened  to  some  extent,  is,  notwithstanding,  very  un- 
yielding, a  young  practitioner  may,  in  the  confusion  and  embar- 
rassment created  by  the  exigency  of  the  case,  easily  run  into  the 
error,  that  this  case  must  be  treated  as  the  one  about  to  be  con- 
sidered. To  avoid  this  error,  he  should  carefully  examine  the 
condition  of  the  os  uteri,  by  placing,  or  rather  hooking  a  finger 
within  it,  and  drawing  the  edge  towards  him:  if  it  readily  yield, 
he  may  be  pretty  certain  it  will  stretch  by  a  well-directed  force 
within  its  circle. 

1077.  But,  in  conducting  this  examination,  I  must  caution  him 
against  a  mistake  he  may  readily  make,  if  he  be  not  put  upon  his 
guard;  which  is  this — he  may  mistake  the  movement  of  the 
whole  OS  uteri,  for  a  portion  of  it;  but  this  error  may  without 
difficulty  be  corrected,  by  deliberately  performing  the  examina- 
tion, and  attending  strictly  to  the  following  marks — if  a  rigid  os 
uteri  be  drawn,  say  towards  the  pubes,  its  edge  under  which  the 
finger  is  placed,  will  retain  its  rigid  feel;  and  if  the  finger  be 
made  to  pass  round  the  whole  of  its  circle,  it  will  be  found  to  be 
uniformly  stiff  and  round,  and  not  any,  or  very  little  enlarged  by 
the  effort  made  upon  it — but,  on  the  other  hand,  if  the  os  uteri 
be  dilatable  beyond  the  size  we  suppose  it  to  be  by  the  touch,  it 
will  be  found  soft;  and  will  yield  without  difficulty  to  the  effort 
made  to  stretch  it:  and  if  the  finger  be  then  allowed  to  pass  round 
it,  it  will  be  perceived  to  be  of  a  lengthened  shape,  and  to  have 
been  entirely  obedient  to  the  force  employed  to  draw  it  forward. 

Sect.  IV. — 4.  TV  here  opened  to  the  same  extent,  but  soft. 

1078.  I  have  just  declared  an  error  may  be  committed  by  an 
inexperienced  or  timid  practitioner  in  this  condition  of  the  uterus; 
and  have  pointed  out  the  method  by  which  it  may  be  instantly 
corrected;  it  therefore  behoves  him  not  to  neglect  to  entirely 
satisfy  himself,  as  to  the  situation  of  the  os  uteri,  before  he  finally 
makes  up  his  opinion  on  the  proper  mode  of  practice. 


UNAVOIDABLE  HEMORRHAGE.  395 

1079.  A  careless  or  ill-conducted  examination,  may  in  this  in- 
stance lead  to  the  loss  of  the  patient;  for,  by  mistaking  the  abso- 
lute diameter  of  the  uterus  for  Xhe  possible,  he  may  delay  opera- 
ting so  long,  as  to  render  it  totally  unavailing;  for  I  perfectly 
agree  with  Dr.  Rigby,*  that  however  important  it  may  be  as  a 
general  rule,  that  the  uterus  must  be  opened  to  the  size  of  a 
shilling,  or  a  half  crown,  before  any  attempt  is  made  to  introduce 
the  hand;  yet  if  this  rule  be  rigidly  enforced,  "it  would  in  some 
cases  be  attended  with  danger,  as  we  might  wait  for  the  opening 
till  it  was  too  late  to  relieve  the  woman  by  turning;  and  for  this 
reason  it  seems  right  we  should  be  sometimes  as  much  influenced 
by  the  os  uteri  being  in  a  state  capable  of  dilatation  without  vio- 
lence, as  by  its  being  nearly  open."t  In  my  directions  for  the 
management  of  cases  in  the  second  condition  of  the  uterus,  I 
noticed  this  situation  of  this  organ,  and  remarked  that  it  usually 
occurred  when  the  woman  had  flooded  to  excess — but  I  have 
known  at  least  two  exceptions  to  this. 

Sect.  V. — 5.   Where  fully  dilated. 

1080.  When  a  case  presents  itself  with  this  condition  of  the 
uterus,  there  can  be  no  hesitation  about  the  proper  mode  of  pro- 
ceeding, if  the  exigencies  require  instant  interference;  for  in  this 
case  all  objection  is  removed  to  the  operation  of  turning,  so  far  as 
any  mechanical  injury  to  the  uterus  is  to  be  feared — but  this  is  a 
rare  case;  and  when  it  does  occur,  it  seems  to  happen  but  under 
the  following  circumstances: — 1st.  In  those  women  who  are  wont 
to  have  very  rapid  and  very  easy  labours.  2dly.  Where  the  edge 
of  the  placenta  extends  over  the  os  uteri,  and  where,  in  conse- 
quence of  this,  the  hsemorrhage  has  not  been  sufficient  to  seriously 
injure  the  contractile  powers  of  the  uterus,  though  rather  profuse. 
3dly.  Where  the  pains  have  been  so  rapid  and  powerful,  as  to 
suddenly  dilate  the  os  uteri,  and  cause  the  head  to  carry  the  pla- 
centa some  distance  before  it. 

1081.  In  the  first  case,  (1080)  the  haemorrhage  will  be  of  the 
most  profuse  and  alarming  kind;  and  if  the  woman  be  not  very 
quickly  aided,  she  will  most  probably  die — this  happened  with 
the  poor  woman  who  died  before  I  got  to  her  assistance — in  this 
situation  of  things  not  a  moment  is  to  be  lost;  turning  must  be  in- 
stantly had  recourse  to. 

*  Rig-by,  p.  42.  f  11^'^.  P*  43. 


396  UNAVOIDABLE  H^IMORRHAGE. 

1082.  In  the  second  instance,  the  discharge,  though  perhaps 
very  free,  is  never  so  overwhelming  as  in  the  first ;  for  the  edge 
of  the  placenta  may  be  passed  over  the  os  uteri  but  a  small  dis- 
tance; the  flooding  will  of  course  be  in  proportion  as  this  may  be 
more  or  less  extensive — in  these  cases  the  membranes  may  even 
present,  rupture  spontaneously,  and  thus  save  the  woman:  here 
the  natural  agents  may  accomplish  the  delivery — but  more  of  this 
by  and  by. 

1083.  In  the  third  case,  the  flooding  will  be  perhaps,  for  a  pe- 
riod, as  alarming,  and  for  the  time  of  its  continuance,  as  profuse 
as  in  the  first — but  the  uterus  acting  promptly  and  vigorously,  the 
head  of  the  child  is  made  to  press  so  effectively  upon  the  mouths 
of  the  bleeding  vessels,  as  to  arrest  the  haemorrhage.*  In  this 
instance  we  must  act  according  to  circumstances;  if  we  see  the 
patient  during  the  time  of  her  profuse  flooding,  we  should  not  he- 
sitate a  moment  to  deliver,  even  though  the  pains  be  brisk;  for  it 
is  entirely  contingent  that  the  discharge  will  be  stopped  by  the 
intervention  of  the  head.  But  should  we  not  see  the  patient  until, 
by  the  progress  of  the  head,  the  bleeding  is  arrested,  we  should 
not  interfere ;  but  commit  the  case  to  nature. 

1084.  It  has  been  recommended  by  some,  to  rupture  the  mem- 
branes, in  the  expectation  of  stopping  the  haemorrhage,  as  fre- 
quently happens  when  the  placenta  is  not  fixed  at  the  mouth  of 
the  uterus — but  this  should  never  be  done;  especially,  before  the 
uterus  is  well  dilated,  or  easily  dilatable,  and  for  the  following  rea- 
sons:— 1st.  Because  they  cannot  be  reached  without  great  diffi- 
culty, in  some  instances,  and  in  these  cases,  when  they  are  reach- 
ed, it  is  either  by  piercing  the  centre  of  the  mass,  or  separating 
a  portion  of  the  placenta,  and  thus  increasing  the  extent  of  the 
bleeding  surface.  2dly.  When  they  are  pierced,  and  the  waters 
evacuated,  it  will  very  rarely  stop  the  haemorrhage.  3dly.  When 
it  does  not  do  this,  we  are  sure  to  have  the  difliculties  of  turning 
increased.  4thly.  Should  the  flooding  for  the  moment  cease  af- 
ter the  discharge  of  the  waters,  it  is  sure  to  return  as  the  pains 
increase,  and  as  the  uterus  expands.  The  only  exceptions  to 
these  rules,  are  the  cases  just  mentioned  above,  where  the  mem- 
branes present  themselves  in  part.   (1082.) 

1085.  Baudelocque  assures  us  he  has  seen  but  one  case,  where 
the  haemorrhage  ceased  after  the  discharge  of  the  waters;  and  in 

*  Baudelocque,  Leroux,  8iC. 


UNAVOIDABLE  HJaMORRHAGE.  397 

that  case  the  placenta  was  first  delivered  by  a  midwife,  and  the 
head  of  the  child  was  made  to  press  so  firmly  on  the  mouths  of 
the  bleeding  vessels  as  to  stop  the  haemorrhage.* 

1086.  It  may  be  inquired,  what  plan  of  relief  is  to  be  pursued 
in  placental  presentations,  when  they  happen  at  or  near  the  sixth 
month?  These,  when  they  occur,  are  truly  embarrassing  cases; 
as,  for  the  most  part,  the  uterus  is  not  sufficiently  enlarged  to  ad- 
mit the  hand  to  turn,  and  the  haemorrhage  is  sometimes  very 
alarming;  the  great  risk  in  this  situation  of  things,  arises  from  the 
want  of  disposition  in  the  os  uteri  to  dilate;  and,  before  this  is 
accomplished,  the  woman  sometimes  succumbs  from  the  unre- 
stained  flow  of  blood. 

1087.  But  women  in  this  situation,  even  when  unaided,  do  not 
necessarily  die;  nature  being  now  and  then  competent  to  the  task 
of  delivery. t  I  may  remark,  as  a  general  rule,  and  as  a  consola- 
tory circumstance,  that  nature,  if  not  interrupted,  or  when  the 
best  chance  is  given  her,  will  almost  always  effect  the  expulsion 
of  the  ovum,  previously  to,  or  soon  after  the  sixth  month,  without 
the  manual  interference  of  the  accoucheur — for  the  most  part, 
then,  in  such  eases,  our  attention  should  be  directed  to  the  dimi- 
nution of  the  haemorrhage,  by  such  palliatives  as  we  have  con- 
stantly in  our  power;  among  these  the  tampon  stands  foremost. 

1088.  This  remedy  should  be  employed  early  in  such  cases, 
as  it  will,  by  proper  management,  save  a  prodigious  expenditure 
of  blood;  and  we  gain  by  its  application,  important  time;  time 
that  is  essential  to  the  successful  delivery  of  the  foetus — for  by 
the  tampon  the  woman's  strength  is  preserved;  pain  is  permitted 
to  increase  ;  and  eventually,  though  tardily,  the  os  uteri  is  dilat- 
ed; the  placenta  and  foetus  thrown  off;  and  the  flooding  almost 
immediately  controlled.  Other  means  should  be  advised,  such 
as  cold  applications  and  the  free  use  of  the  acetate  of  lead;  but 
above  all,  if  the  uterus  be  disposed  to  dilate,  the  secale  cornutum. 
These  may  powerfully  aid  the  general  intentions,  and  render  the 
operation  of  the  tampon  more  certain. 

1089.  Mauriceau  and  others  attempted  the  relief  of  the  wo- 
man by  manual  exertion  under  such  circumstances ;  but  I  should, 
neither  from  the  history  of  their  cases,  nor  my  own  experience, 
be  tempted  to  recommend  their  plan.  I  am  persuaded,  that  the 
temporizing  mode  I  have  just  suggested,  is  the  proper  one  to  pur- 

*  System,  Vol.  II.  pai-.  982. 
f  Rigby,  Leroux,  &c. 


398  UNAVOIDABLE  HEMORRHAGE. 

sue — Leroux  long  since  adopted  this  method,  and  I  have  for  many 
years  but  trod  in  his  footsteps;  and  it  is  but  just  and  proper  to 
add,  I  have  had  abundant  reason  to  be  satisfied.  Besides,  in  this 
opinion  all  the  best  writers  concur. 

1090.  Dr.  Rigby,  though  by  no  means  confident  of  the  efficacy 
of  the  tampon,  confesses,  in  the  cases  I  am  now  considering,  it 
might  be  used  with  propriety.  Had  he  put  this  plan  in  execu- 
tion, I  am  persuaded  he  would  have  been  satisfied  with  its  effects, 
and  would  unquestionably  have  prevented  his  giving  the  hazard- 
ous advice,  "to  wait  for  relaxation,"  by  permitting  the  patient  to 
flood,  until  the  collapse  almost  of  death  should  effect  it. 

1091.  Experience  has  often  convinced  me,  that  the  relaxation 
of  the  OS  tincae,  so  desirable  in  the  cases  I  am  now  considering, 
will  be  as  certainly  achieved  by  time,  as  by  this  excessive  expen- 
diture of  blood;  and  this  time  may  be  procured  by  the  iiiter- 
ruption  of  the  flooding  hy  \he  id^m-^Qu.  When  we  effect  this, 
we  assuredly  gain  a  great  deal — strength  is  saved,  by  saving 
much  blood:  and  the  woman's  future  safety  is  almost  insured; 
for  as  a  general  rule  we  may  declare,  that  when  no  violence  is 
committed  upon  the  uterus  by  an  attempt  at  forced  delivery,  the 
only  thing  to  be  apprehended,  is  the  consequences  of  the  haemor- 
rhage. 

1092.  When  the  woman  is  farther  advanced,  say  at  the  se- 
venth month,  artificial  delivery  may  most  generally  be  effected,* 
provided  we  do  not  destroy  the  advantages  this  more  advanced 
period  gives  us,  by  improper  treatment; — for  instance,  by  rup- 
turing the  membranes,  and  the  consequent  discharge  of  the  waters; 
this  should  therefore  be  especially  guarded  against.  An  attention 
to  this  point  in  these  cases,  is  more  important  than  at  the  full 
period;  notwithstanding  the  advice  of  some  accoucheurs  to  the 
contrary. 

1093.  It  now  only  remains  to  describe  the  mode  of  effecting 
the  delivery,  when  it  is  judged  proper  it  shall  be  performed.  In 
doing  this,  we  can  give  only  general  directions  for  placing  the 
woman,  as  we  cannot,  from  extreme  weakness,  or  from  other 
causes,  always  command  the  most  proper  or  convenient;  it  may 
nevertheless  be  well  when  we  have  a  control  over  circumstances, 
to  point  out  that  which  in  our  opinion  is  best — that  disposition 
of  the  woman's  body,  which  will  give  us  the  most  entire  com- 

*  Leroux,  Rigby,  &.c. 


UNAVOIDABLE  HJEMORRHAGE.  399 

mand  of  the  uterus  and  its  contents,  will  certainly  be  the  most 
convenient  for  the  accoucheur,  and  also  the  safest  for  the  woman, 
and  this  position  is  upon  the  back ;  as  has  already  been  directed. 
(732,  &c.) 

1094.  Many  accoucheurs,  and  especially  the  British,  recom- 
mend the  patient  to  be  placed  upon  the  side  ;  I  have  ever  found 
this  position  less  convenient  than  the  one  just  suggested ;  and 
have  therefore  always  adopted  it,  where  the  situation  of  the  wo- 
man would  permit  a  choice,  without  injury.  The  advantages  of 
this  position  are  first,  we  may  employ  either  hand  as  may  be  most 
convenient  to  the  practitioner,  without  changing  the  situation  of 
the  patient.  Secondly,  we  always  have  one  hand  at  liberty  to 
co-operate  with  the  introduced  one,  by  placing  it  upon  the  abdo- 
men. Thirdly,  we  can  pass  the  hand  more  readily  in  the  axis  of 
the  superior  strait,  by  having  the  perinaeum  free  over  the  edge  of 
the  bed.  Fourthly,  we  can  regulate  the  discharge  of  the  liquor 
amnii,  ad  libitum,  a  matter  sometimes  of  great  moment.*  But  it 
must  be  remembered,  we  are  never  to  attempt  to  procure  these 
advantages  by  moving  the  patient,  when  that  movement  would  be 
injurious  to  her:  therefore,  when  she  is  very  weak  or  faint,  we 
must  operate  as  well  as  we  can  in  the  position  we  find  her;  this 
is  sometimes  very  awkward  and  inconvenient,  but  these  are  of  no 
consideration,  when  her  life,  perhaps,  is  to  be  put  in  competition 
with  our  ease.  For  the  most  part,  there  is  not  much  to  be  appre- 
hended from  merely  changing  the  woman  from  her  back,  should 
she  be  lying  upon  it,  to  her  side:  but  a  greater  change  might  be 
very  mischievous:  we  are  therefore  frequently  obliged  to  do  this 
before  we  can  operate,  as  it  would  be  almost  impossible  to  turn, 
when  the  patient's  back  and  hips  are  at  some  distance  from  the 
edge  of  the  bed.t 

1095.  Should  circumstances,  or  choice  induce  me  to  deliver 
from  the  side,  I  always  give  a  preference  to  the  left,  provided 
an  election  can  be  made.     The  hips  should  be  drawn  near  to  the 

*  Dr.  Ryan,t  seems  a  little  surprized  at  this  direction,  and  asks,  "how  can 
this  fluid  escape,  if  the  wrist  or  arm  fills  the  vagina?"  It  cannot,  if  the  arm 
should  literally  fill  the  vagina— but  it  never  does  so,  strictly,  agreeably  to  my  own 
experience,  but  what  the  liquor  amnii  would  escape,  if  the  membranes  be 
pierced  near  the  os  uteri.  But  this  precaution  is  recommended  only  in  the 
unavoidable  haemorrhage. 

f  We  must  always  remember  to  have  pressure  made  upon  the  abdomen  by  a 
judicious  assistant,  when  we  deliver  the  woman  upon  the  side;  as  we  cannot 
in  this  position,  as  when  she  is  upon  her  back,  perform  it  ourselves. 

i  Manual  of  Midwifery,  3d  Vol. 


400  UNAVOIDABLE  HAEMORRHAGE. 

edge  of  the  bed,  and  made  as  salient  almost  as  may  be,  by  the 
flexion  of  the  body,  and  the  drawing  up  of  the  knees.  In  this 
position  the  left  hand  is  to  be  used,  as  with  the  right  it  would  be 
very  difficult  to  operate,  owing  to  the  axis  of  the  superior  strait 
being  very  much  in  advance.  If,  on  the  right  side,  the  right 
hand  should  be  employed,  and  for  the  reason  just  stated. 

1096.  The  woman  being  properly  placed,  (if  in  our  power;) 
the  hand  should  be  gradually  and  gently  introduced  into  the  va- 
gina, and  then  into  the  mouth  of  the  uterus,  separating  the  pla- 
centa and  membranes  from  it  as  it  advances  towards  the, fundus 
— when  arrived  there,  the  membranes  should  be  broken  by  press- 
ing firmly  against  them;  but  the  waters  should  not  be  permitted 
to  escape  but  at  our  pleasure. 

1097.  We  can  command  this  almost  always,  as  our  arm  fills  up 
the  OS  externum,  and  prevents  it  passing  out — from  time  to  time 
some  is  permitted  to  escape  by  pressing  the  arm  firmly  against  one 
side  of  the  vagina,  until  a  sufficient  quantity  has  been  evacuated; 
the  object  of  this  gradual  discharge  of  the  waters  is  at  once  ob- 
vious; it  prevents  the  uterus  from  falling  into  a  state  of  atony,  by 
its  being  too  suddenly  deprived  of  them.  The  feet  are  now  to 
be  seized,  and  the  body  made  to  descend  by  drawing  them  down 
to  the  superior  strait.  We  should  now  allow  a  little  time  for  the 
uterus  to  contract;  when  we  are  assured  that  it  has  done  so,  either 
by  pains  declaring  themselves  by  the  child  advancing  farther  into 
the  pelvis  without  our  exertion,  or  by  the  firm  and  hardened  feel 
of  the  uterus  through  the  parietes  of  the  abdomen,  vve  may  most 
safely  proceed  to  finish  the  delivery. 

1098.  But  should  the  woman  be  very  much  exhausted  before 
we  commence  our  operations,  we  should  use  additional  caution 
in  the  delivery — it  must  be  very  slowly  performed,  and  we 
should  have,  at  each  step  of  the  progress,  assurances,  if  possible, 
that  the  uterus  has  not  lost,  or  rather  that  it  possesses,  sufficient 
contractility  to  render  the  completion  of  the  operation  eventually 
safe,  if  performed  with  due  and  necessary  care. 

1099.  We  are  advised  by  some,  to  pierce  the  placenta  by  the 
hand;  but  this  should  never  be  done;  especially,  as  it  is  impossi- 
ble to  assign  one  single  good  reason  for  the  practice,  and  there 
are  several  very  strong  ones  against  it.  1st.  In  attempting  this, 
much  important  time  is  lost,  as  the  flooding  unabatedly,  if  not 
increasingly  goes  on.  2dly.  In  this  attempt  we  are  obliged  to 
force  against  the  membranes,  so  as  to  carry  or  urge  the  whole  pla- 


TJNAVOIDABLK   H^^iMOitUHAGE.  401 

centary  mass  towards  the  fundus  of  the  uterus,  by  which  means, 
the  separation  of  it  from  the  neck  is  increased,  and  consequently 
the  flooding  augmented.  3dly.  When  the  liand  has  even  pene- 
trated the  cavity  of  the  uterus  through  the  placenta,  the  hole 
which  is  made  is  no  greater  than  itself;  and,  consequently,  much 
too  small  for  the  ffi^tus  to  pass  through,  unless  we  force  an  en- 
largement; and  this  can  only  be  done  by  the  child  during  its 
passage.  4thly.  As  the  hole  made  by  the  body  of  the  child  is 
not  sufficiently  large  for  the  arms  and  head  to  pass  through  at  the 
same  time,  they  will  consequently  be  arrested,  and  if  force  be 
applied  to  overcome  the  resistance,  it  will  almost  always  separate 
the  whole  of  the  placenta  from  its  connection  with  the  uterus,* 
5thly.  That  when  this  is  done,  it  never  fails  to  increase  the  dis- 
charge; besides  adding  the  bulk  of  the  placenta  to  that  of  the  arms 
and  head  of  the  child.  6thly.  When  the  placenta  is  pierced, 
we  augment  the  risk  of  the  child;  for  in  making  the  opening,  we 
may  destroy  some  of  the  large  umbilical  veins,  and  thus  permit  the 
child  to  die  from  haemorrhage. t J  7thly.  By  this  method,  we  in- 
crease the  chance  of  an  atony  of  the  uterus,  as  the  discharge  of 
the  liquor  amnii  is  not  under  due  control.  Sthly.  That  it  is 
sometimes  impossible  to  penetrate  the  placenta;  especially  when 
its  centre  answers  to  the  centre  of  the  os  uteri;  in  this  case  much 
time  is  lost,  that  may  be  very  important  to  the  woman. § 

1100.  It  is  a  mistake  to  suppose  we  produce  a  greater  separa- 
tion of  the  placenta  Vy^hen  we  pass  the  hand  between  it  and  the 
uterus,  than  when  we  pierce  the  placenta.  But  if  it  were  true, 
it  would  be  no  objection  to  the  method  I  advocate,  since  both 
uterus  and  placenta  are  pretty  firmly  compressed  by  the  arm  in 
its  passage  to  the  fundus,  and  the  bleeding  by  this  means  re- 
strained; and  as  this  is  the  only  objection  which  is  raised  against 
the  method  recommended,  I  shall  consider  it  as  completely  an- 
swered by  what  is  now  said. 

1101.  Should  the  placenta  not  be  found  entirely  detached  from 
the  uterus  after  the  birth  of  the  child,  we  should  give  a  little  time 
for  it  to  separate  spontaneously;  and  we  must  endeavour  to  pro- 

•  Baudelocque.  -{-  Baudelocque. 

+  Dr.  Denman  confesses,  though  he  recommends  the  searching-  for  an  edge 
of  the  placenta,  and  penetrating  it,  that,  in  performing  the  latter  "there  is  ra- 
ther more  danger  of  loosing  the  chM."—3Iidwifcrt/,  Francis's  ed.  p.  484. 

§  Dr.  Rigby  admits  this,  and  declares  he  has  "more  tlian  once  found  it." 
p.  64. 

51 


402  UNAVOIDABLE  H^MORRHAGK. 

mote  this  by  friction  upon  the  abdomen  over  the  uterus,  unless 
the  flooding  continues  to  be  violent ;  it  will  then  be  proper  to  pass 
up  the  hand  and  separate  it,  for  it  may  be  the  bulk  of  the  placenta 
which  keeps  up  the  hEemorrhage;  by  preventing  the  uterus  from 
closing  sufficiently  upon  the  bleeding  vessels. 

1102.  Before  I  proceed  farther,  it  may  be  well  to  inquire  into 
Dr.  Rigby's  opinion  concerning  the  nature  of  the  uterine  vessels, 
which  I  am  content  to  call  arteries.  He  says,  "the  uterine  ves- 
sels differ  very  materially  from  arteries,  and  particularly  in  hav- 
ing no  such  power  of  contraction  within  themselves,  their  con- 
traction and  dilatation  being  absolutely  dependent  upon  the  state 
of  the  uterus.  In  the  unimpregnated  state  they  are  so  small  as 
scarcely  to  be  discovered;  but  they  are  well  known  to  increase 
when  the  uterus  receives  the  ovum,  and  to  grow  in  exact  pro- 
portion to  its  gravidity;  and  when  by  the  complete  distention  of 
it,  they  have  acquired  their  utmost  magnitude,  their  diameters 
cannot  be  lessened  until  the  womb,  being  again  emptied,  closes 
them  by  the  contraction  of  its  whole  capacity,  and  restores  them 
to  their  original  size." 

1103.  There  is  no  one  circumstance  in  this  history  that  would 
lead  me  to  reject  the  idea,  that  a  part  of  the  uterine  vessels  are 
arteries,  and  for  the  following  reasons:  1st,  the  spermatic  and 
hypogastric  arteries  furnish  the  uterus  with  these  vessels;  and  it 
is  well  known  that  they  increase  in  proportion  as  gestation  ad- 
vances; consequently,  vessels  which  all  agree  are  arteries,  enlarge, 
and  in  almost  the  same  degree  as  those  within  the  substance  of 
the  uterus,  which  are  but  continuations  of  them;  2d,  no  physical 
difference  has  ever  been  discovered  between  them. 

1104.  These  two  circumstances  I  consider  in  themselves  as 
conclusive  of  the  identity  of  the  uterine,  and  the  spermatic  and 
hypogastric  arteries.  If  not  so,  why  should  these  vessels  enlarge 
in  proportion  to  each  other?  And  why  should  the  spermatic  and 
hypogastric  arteries  contract  when  delivery  has  taken  place,  with- 
out being  dependent  for  this  effect  upon  the  "  contraction  of  the 
uterus?"  Now  let  us  see  what  would  really  present  itself,  were 
Dr.  R.'s  opinion  substantially  true;  he  declares,  in  the  unim- 
pregnated state  of  the  uterus,  that  these  vessels  "  are  so  small  as 
scarcely  to  be  perceived."  Now,  how  should  this  happen  if  they 
possessed  no  contractile  power  within  themselves?  The  mere 
contraction  of  the  uterus  could  not  alter  their  real  capacity;  it 
could  only  change  their  form  by  strongly  compressing  them; 


UNAVOIDABLE  HAEMORRHAGE.  403 

therefore,  if  what  he  supposes  were  even  true,  they  should  con- 
stantly present  to  us  the  shape  of  flattened  cylinders  or  puckered 
tubes;  but  the  contrary  of  all  this  appears  when  we  cut  into  the 
substance  of  the  uterus,  for  we  then  find  that,  though  the  vessels 
are  ''  so  small  as  scarcely  to  be  perceived,"  yet  those  we  do  see, 
constantly  present  to  us  a  circular  form. 

1105.  That  they  do  not  contract  during  pregnancy,  or  imme- 
diately after  delivery,  as  closely  as  arteries  in  many  other  parts 
of  the  body  do,  I  admit;  not  because  they  do  not  possess  con- 
tractibiiity  in  an  equal  degree  with  these,  but  because  they  can- 
not exert  it  to  the  same  extent,  in  consequence  of  their  peculiar 
connection  with  the  general  substance  of  the  uterus — they  are 
ever}'^  way  surrounded  by,  and  connected  with,  cellular  mem- 
brane,* which  will  permit  them  to  lessen  themselves  but  to  a  cer- 
tain degree,  so  long  as  the  muscular  fibres  of  the  uterus  remain  in 
an  uncontracted  state,  and  for  this  plain  reason,  that  the  sum  of 
their  power  or  disposition  to  shut  themselves  up,  is  inferior  to  the 
power  which  keeps  them  in  some  measure  upon  the  stretch.  But 
that  they  do  diminish  in  size  to  a  certain  degree,  after  being  ex- 
posed by  a  separation  of  a  portion  of  the  placenta  during  preg- 
nancy, I  have  no  doubt,  as  the  cellular  membrane  by  which  they 
are  surrounded,  will  from  its  elasticity,!  permit  them  to  do  so, 
and  thus  contribute  to  the  suppression  of  haemorrhage. 

1106.  We  must  regard  the  uterus  during  gestation,  as  in  a  state 
of  coercion— every  part  and  portion  of  it  sooner  or  later  is  put 
upon  the  stretch;  consequently,  the  vessels  entering  into  its  sub- 
stance must  enlarge  with  it,  or  put  the  cellular  membrane,  by 
which  they  are  surrounded  upon  the  stretch;  but  as  there  is  a 

*  I  am  not  wishing  to  be  understood,  that  there  is  anything  peculiar  in  the 
uterine  arteries  being- surrounded  with  cellular  membrane;  for  this  we  know 
obtains  wherever  there  are  arteries — I  merely  wish  to  insinuate  an  opinion,  that 
they  have  positively  less  freedom  than  the  arteries  in  the  other  parts  of  the  bo- 
dy, by  Ijeing  more  closely  tied  by  their  connecting  media,  and  tliat,  as  I  shall 
immediately  say,  for  very  important  uses:  and  that  they  have  relatively  less, 
would  appear  evident,  when  we  reflect  on  the  immense  increase  they  suffer  du- 
ring gestation;  and  though  they  may  contract  very  considerably,  yet  it  may  be 
insufficient  to  stop  their  bleeding  without  the  co-operating  contraction  of  the 
muscular  fibres,  for  the  reason  I  shall  presently  assign.  Levret  makes  the  pro- 
portion of  the  unlmpregnated  uterus,  to  that  of  the  impregnated,  to  be  as  eleven 
and  a  half  to  one.  Now,  if  the  arteries  augment,  (as  it  is  reasonable  to  suppose 
they  do,)  in  the  same  proportion,  it  will  be  seen  how  much  their  calibers  must 
be  reduced,  before  their  contraction  alone  can  stoj)  haemorrhage. 

I  Bichat,  Anatom.  Gen. 


404  UNAVOIBABLE  HiEMORRHAGE, 

most  important  intention  to  be  fulfilled  by  their  enlargement,they 
are  found  to  augment  in  a  ratio  correspondent  to  the  distention  of 
the  uterus;  and  they  are  not  only  made  to  yield  in  proportion  to 
the  increased  demand  for  blood;  but  are  also  kept  in  that  state 
by  its  constant  influx,  to  supply  the  exigencies  of  the  uterus  in  a 
state  of  gravidity. 

1107.  This  condition  of  the  uterine  vessels,  then,  has  two  causes 
contributing  to  the  same  end — namely,  the  unfolding  and  separa- 
ting of  the  fibres  constituting  the  proper  substance  of  this  organ, 
and  the  constantly  increasing  tide  of  blood  which  flows  within  it: 
the  first,  if  it  does  not  directly  administer  to  the  enlargement  of 
these  vessels,  will,  to  a  certain  extent,  favour  it,  by  taking  off  that 
restraint  which  a  state  of  contraction  imposes  upon  them,  and 
thus  make  them  more  certainly  obedient  to  the  impulses  of  the 
spermatics  and  hypogastrics — the  vis  a  tergo,  of  these  vessels, 
may  be  considered  as  essentially  contributing  to  their  distention. 
Hence  we  can  no  longer  recognize  the  almost  imperceptible  ves- 
sels of  the  unimpregnated,  in  the  large  canals,  if  we  may  so  term 
them,  in  the  advanced  impregnated  uterus. 

1108.  Let  us  now  suppose  the  supply  to  the  uterine  vessels  to 
be  cut  off  by  any  means  whatever,  and  we  make  a  section  of  the 
uterus  near,  or  at  the  full  time  of  gestation,  and  while  yet'  occu- 
pied by  the  ovum — what  will  this  section  discover  to  us?  One  of 
two  things  certainly — either  the  vessels  small  and  contracted,  or 
still  patulus  and  large.  If  in  the  first  situation,  Dr.  Rigby's  opin- 
ion of  their  nature,  is  at  once  proved  to  be  unfounded;  if  in  the 
latter,  will  it  not  confirm  the  notion  I  entertain,  that  they  are 
kept  in  this  situation  by  force,  as  above  suggested?  (1105)  If  this 
be  true,  will  not  the  same  cause  produce  the  same  effect,  when 
the  uterus  is  emptied  of  its  contents,  but  remains  in  a  flaccid  and 
uncontracted  state?  And  will  not  the  same  consequences  follow 
from  tlie  same  cause  in  both  instances,  namely,  a  discharge  of 
blood  from  the  separation  of  the  whole,  or  a  part  of  the  placenta?* 

*  I  might  also  insist,  that,  should  tlie  uterine  vessels  be  found  large  and  pat- 
ulous when  the  flaccid  uterus  was  cut  into,  that  it  would  not  confii-m  Dr.  R.  's 
ophiion,  should  the  explanation  just  offered  be  admitted;  as  it  might  be  a  rea- 
sonable conjecture  to  suppose  that  a  cause  capable  of  producing  an  atony  of 
the  muscular  fibres  of  the  uterus,  might  also  be  capable  of  rendering-  the  uterine 
ai-teries  passive;  and  consequently,  this  uncontracted  condition  of  them  would 
tend  to  prove  that  this  was  really  the  case,  rather  than  that  they  had  been  en- 
dowed with  the  power  of  self-diminution. 


UNAVOIDABLE  H^.MORRIIAGE.  405 

1109.  If  these  statements  be  true,  (and  I  sincerely  believe  them 
to  be  substantially  correct,)  it  will  follow,  that  the  uterine  arteries 
cannot  contract  sufficiently  to  stop  haemorrhage,  however  emi- 
nently they  may  possess  contractibilit}^,  so  long  as  the  muscular 
fibres  of  the  uterus  are  in  an  uncontracted  state;  because  their  pe- 
culiar connexion  with  them,  will  necessarily  prevent  it — and  far- 
ther, I  believe,  that  this  kind  of  union  highly  contributes  to  the 
safety  of  the  patient,  after  the  expulsion  of  the  foetus,  by  enabling 
it,  or  perhaps  I  may  say  inducing  it  to  contract,  to  throw  off  the 
placenta,  and  prevent  after  hsemorrhage, 

1110.  They  perform  this  valuable  end  by  lessening  themselves, 
and  obliging,  in  a  certain  degree,  the  muscular  fibres  to  follow 
them — and  this  contraction  proves  an  extensive  and  congenial 
stimulus,  and  is,  for  the  most  part  successfully  exerted  to  this 
end — but,  should  the  muscular  fibres  of  the  uterus  be  indisposed, 
or  unable,  from  the  operation  of  any  suflicient  cause  to  manifest 
a  contractile  power,  haemorrhage  must  necessarily  ensue.  For 
the  arterial  extremities,  which  are  exposed  by  the  separation  of 
the  placenta,  will  and  must  remain  open,  not  because  they  do  not 
possess  the  faculty  of  contraction,  but  because  it  cannot  be  suc- 
cessfully exerted,  for  the  reasons  I  have  already  assigned — there- 
fore, that  haemorrhage  may  cease,  it  is  necessary  to  ensure  the 
co-operation  of  the  contractile  fibres  of  the  uterus,-  and  to  make 
them  obedient  to  this  end,  is  the  great  aim  of  all  our  exertions. 

1111.  From  a  review  of  the  inquiry  I  have  just  made,  it  will 
be  evident,  that  as  far  as  regards  effects,  there  is  but  little  differ- 
ence between  Dr.  Rigby  and  myself;  but  much,  as  regards  struc- 
ture and  function — my  object,  in  this  attempt,  is  the  removal  of 
error,  and  not  the  expectation  of  any  great  practical  advantage, 
though  I  am  persuaded  some  benefit  may  be  derived  from  these 
considerations,  in  the  cure  of  haemorrhages  of  this  kind — for,  upon 
the  notion  of  the  uncontractibility  of  the  uterine  arteries,  Dr.  R. 
condemns  the  use  of  that  class  of  medicines  called  astringents; 
and  from  the  use  of  which,  I  have  frequently  found  advantage; 
for  the  sugar  of  lead  must  be  admitted  to  be  an  astringent;  and 
in  cases  of  flooding,  one  of  no  conimon  power — in  the  modus  ope- 
randi of  this  medicine  I  may  be  mistaken,  but  I  cannot  be  in  its 
effects.  There  may  be  many  other  substances  belonging  to  this 
class  which  may  be  equally,  or  even  more  efficacious  upon  trial; 
but  we  shall  be  deterred  from  employing  them  if  we  subscribe 
to  the  opinion  of  Dr.  Rigby,  that  the  uterine  arteries,  "  cannot 
contract  of  themselves. " 


406  UNAVOIDABLE  HEMORRHAGE. 

1112.  The  unavoidable,  and  haemorrhage  after  the  birth  of  the 
child,  are  every  way  so  interesting  from  their  frequency,  and 
danger,  that  we  feel  ourselves  justified  in  offering  every  novel 
suggestion  that  presents  itself  to  our  reading,  or  to  our  observa- 
tion. We  do  this  for  two  reasons;  first,  to  put  our  readers  in  pos- 
session of  the  viewsof  other  practitioners;  and  secondly,  that  we 
may  have  an  opportunity  to  offer  our  remarks  upon  the  opinions, 
and  suggestions  of  others,  when  such  suggestions  do  not  appear  to 
us  either  very  practicable,  or  very  useful.  With  these  objects  in 
view,  we  shall  relate  what  we  have  collected  since  the  second 
edition  of  this  work  went  to  press,  upon  these  important  points. 

^'  Jl  Case  of  Fatal  Hsemorrhage  at  the  seventh  month  of  Utero- 
gestation,  from  the  placenta  being  placed  over  the  mouth  of 
the  Uterus,  together  with  remarks  upon  it,  and  several  other 
modes  of  treating  Uterine  Hsemorrhage. " 

1113.  In  this  case  it  is  stated  that  the  patient  lost  three  pints 
ofblood;  she  became  faint:  pulseninety  and  firm;  os  uteri  admit- 
ted the  point  of  tlie  finger,  but  nothing  unusual  could  be  discover- 
ed. Rest,  cold,  opium,  and  sulphuric  acid,  were  prescribed.  Pro- 
fuse hfcrnorrhage  followed  after  some  hours,  probably  eight,  as  the 
medicines  were  directed  every  four  hours,  and  it  was  after  the 
third  dose  a  profuse  haemorrhage  followed.  But  before  Dr.  James, 
the  narrator,  could  arrive,  the  woman  was  in  a  dying  state. 

1114.  Finding  a  large  portion  of  the  placenta  in  the  vagina, 
and  the  os  uteri  fully  dilated,  he  endeavoured  to  thrust  his  finger 
through  the  weakest  edge  of  the  placenta;  but  failing  in  this  at- 
tempt, he  perforated  the  centre  of  this  mass,  seized  the  feet  of  the 
child,  and  brought  them  into  the  vagina.  A  pain  came  on,  but 
was  not  repeated;  and  as  haemorrhage  followed,  the  child  was  ex- 
tracted by  mechanical  means.  Contraction  of  the  uterus  was  so- 
licited by  the  introduction  of  the  hand;  pressure  was  made  upon 
the  abdominal  aorta  to  lessen  the  extent  of  the  heart's  circulation, 
but  all  to  no  purpose.     ''  Life  was  gone."* 

1115.  The  history  of  this  case  gives  rise  to  the  following  sug- 
gestions. First.  It  appears  extraordinary,  that  "  nothing  unusual 
could  be  discovered  by  the  touch;"  or,  in  other  words,  that  the 
placenta  could  not  be  detected  upon  examination,  as  the  os  uteri 

*  North  Amer.  Med.  and  Sm-g.  Journ.  No.  5,  p.  203,  from  the  Lond.  Med. 
Kep.  for  September,  1826. 


i 


UNAVOIDABLE  HiEMORRHAGE.  407 

admitted  the  point  of  the  finger;  especially,  as  this  mass  must  have 
been  within  reach,  if  a  search  had  been  made,  as  I  have  recom- 
mended, (1026)  by  the  introduction  of  the  hand  into  the  vagina, 
instead  of  the  finger  alone.  It  may  therefore  be  proper  to  insist 
again  upon  this  being  done,  whenever  the  degree  of  flooding  ren- 
ders it  desirable  to  determine  whether  the  hasmorrhage  be  of  the 
accidental,  or  of  the  unavoidable  kind;  and  this  must  be  the  case 
always  when  the  discharge  is  very  profuse. 

1116.  Second.  That  a  patient,  who  had  lost  "  three  pints  of 
blood,"  and  was"  faint,"  should  be  trusted  to  the  powers  of  opium, 
acids,  &c.  and  the  practitioner  to  feel  so  much  confidence  in  them, 
as  to  leave  her  for  eight  hours  to  their  sole  influence.  In  this  case 
the  patient  should  have  been  narrovsdy  watched,  and  the  tampon 
should  have  been  introduced.  (1071.) 

1117.  Third.  It  is  evident  from  the  statement  that  artificial  de- 
livery could  have  been  performed,  most  probably,  a  long  time 
before  it  was,  as  upon  the  return  of  Dr.  James,  '«a  large  portion 
of  the  placenta  was  found  protruding  through  a  fully  dilated  os 
uteri;"  consequently,  precious  time  was  unnecessarily  lost,  and 
the  danger  of  the  patient  augmented. 

Ills.  Fourth.  That  the  efforts  of  the  practitioner  to  procure  the 
contraction  of  the  uterus  should  not  have  been  confined  to  the  in- 
troduction of  the  hand  alone.  Brisk  frictions  should  have  been 
made  upon  the  abdominal  parietes;  and  the  ergot,  or  sugar  of  lead, 
should  have  been  given,  before  any  attempt  was  made  to  deliver 
the  child;  nor  should  time  liave  been  lost  in  the  attempt  to  pierce 
any  portion  or  part  of  the  placenta;  the  hand  should  have  been 
immediately  passed  between  the  uterus  and  the  membranes;  the 
latter  of  which,  would  have  been  easily  broken,  and  this  witliout 
the  loss  of  a  moment  of  time. 

1119.  Fifth.  No  kind  of  reliance  can  be  placed  upon  the  at- 
tempt to  diminish  the  "extent  of  the  heart's  circulation,"  by 
pressing  the  aorta;  for  the  tonic  contraction  of  the  uterus  is  alto- 
gether independent  of  the  general  or  local  circulation  of  the  blood. 
Besides  we  do  not  think  it  possible  to  obliterate  this  enormous 
vessel  by  any  means  yet  contrived;  the  pressure  of  the  hand  is 
certainly  incompetent  to  such  an  effect;  and  if  more  rude  means 
be  employed,  the  parts  interposing  between  the  compressing 
power  and  spine  may  suffer  severely — the  attempt  moreover,  is 
but  losing  precious  time.  But  let  us  suppose,  that  the  circulation 
in  the  aorta  is  temporarily  suspended;  will  this  secure  the  patient 


408  UNAVOIDABLE  HEMORRHAGE. 

against  the  renewal  of  the  flooding  when  the  pressure  is  removed? 
Certainly  it  will  not;  unless  the  uterus  has  spontaneously  con- 
tracted ;  and  if  it  be  contracted,  there  can  be  no  necessity  for 
pressure  upon  the  aorta. 

1120.  It  may,  however,  be  said  that  we  may  gain  time  by  this 
plan,  and  thus  give  a  greater  opportunity  for  the  uterus  to  con- 
tract. This  is  vastly  more  specious  than  solid,  for  by  directing 
our  attention  to  the  pressure  upon  the  aorta,  we  prevent  the  em- 
ployment of  friction  upon  the  abdomen,  which  is  much  more  im- 
portant. Besides,  the  uterus  is  always  found  in  such  cases  in  one 
of  two  conditions;  namely,  either  entirely  flaccid,  or  very  par- 
tially contracted.  If  in  the  first,  it  must  be  included  between  the 
means  employed  for  the  external  pressure,  and  the  spine;  con- 
sequently, it  may  be  severely  injured  by  a  force  that  is  equal  to 
stopping  the  circulation  in  the  aorta.  If  in  the  second,  it  will  be 
found,  that  no  force,  which  can  be  safely  applied,  will  compress 
the  aorta  successfully,  through  the  abdominal  and  uterine  pa- 
rietes;  for  it  must  be  borne  in  mind,  that  the  uterus  in  either  of 
the  supposed  cases,  will  be  above  the  umbilicus;  and  consequently 
will  interfere  with  the  attempt  at  pressure. 

1121.  With  the  same  object  in  view.  Dr.  James  also  recom- 
mends the  use  of  tourniquets  to  the  extremities;  we  fear  this 
plan,  like  the  one  just  noticed,  will  be  found  equally  unavailing, 
even  supposing  the  proper  instruments  to  be  at  hand.  Of  a  simi- 
lar character  is  the  proposal  of  Dr.  Mojon  to  throw  into  the  um- 
bilical vein,  after  having  expressed  from  it  as  much  of  the  blood 
it  contains  as  is  practicable,  as  great  a  quantity  of  acidulated 
water  as  it  will  receive  by  means  of  a  syringe.  He  declares 
this  to  have  succeeded:  and  requests  others  to  repeat  it.  He 
says  it  required  to  be  pushed  with  both  force  and  promptitude. 
He  thinks  that  the  sensation  of  cold  which  the  uterus  perceives 
when  cold  liquor  is  injected,  favourably  promotes  the  separation 
of  the  placenta.* 

1122.  The  notice  we  have  of  this  new  method  of  relieving  the 
placenta  in  cases  of  hcemorrhagy  is  very  imperfect ;  for  we  are 
not  informed  of  the  condition  of  the  uterus  previously  to  the  in- 
jection of  the  acidulated  water;  whether  it  was  in  a  slate  of  in- 
ertia; or  whether  it  was  owing  to  an  unusual  obstinacy  of  adhe- 
sion; or  whether  any  attempt  had  been  previously  made  to  ar- 

*  Revue  Medicate,  &c.  for  June,  1826,  p.  502. 


UNAVOIDABLE  HiEMOKRHAGE.  409 

rest  tiie  discharge,  and  it  had  failed.  For  we  must  declare,  that 
merely  to  save  the  introduction  of  the  hand,  as  he  avows,  is  hy 
no  means  sufficient  to  seduce  a  well-instructed  accoucheur  to 
depart  from  a  method  which  has  been  successful  for  centuries, 
and  which,  in  general,  is  not  attended  by  either  difficulty  or  dan- 
ger. Besides,  it  may  well  be  questioned,whether  the  liquid  em- 
ployed by  Dr.  Mojon  had  any  agency  in  relieving  the  placenta 
from  its  adhesion;  as  we  well  know  that  this  mass  is  often  very 
suddenly  thrown  off  without  any  interference.  Moreover  it  can 
only  be  useful  in  such  cases,  (if  it  ever  be  useful,)  as  are  attended 
with  a  jxirtial  sejuiration  of  the  placenta;*  a  condition,  we  are 
bold  to  say,  neither  Dr.  Mojon  or  any  other  man,  can  determine 
with  certainty  without  the  introduction  of  the  hand  if  it  be  essen- 
tial that  this  point  shall  be  determined  ;  and  if  this  be  necessary, 
as  we  believe  it  would  Ix;,  the  hand  had  much  better  perform  its 
duty,  while  it  has  possession  of  the  uterine  cavity,  than  to  be 
withdrawn  to  aid  in  the  injection  of  a  cold  acidulated  water. 

1123.  Again,  all  the  pains  just  noticed,  necessarily  suppose, 
that  all  the  mechanical  agents  necessary  to  fulfd  the  indica- 
tions, (and  we  see  these  are  sufficiently  varied,)  are  at  hand,  and 
can  be  called  into  requisition,  sur  le  chamjj;  for  these  cases  admit 
of  no  delay  when  extreme;  and  it  is  only  when  extreme,  that  they 
are  proposed,  or  can  be  proper ;  were  these  methods  to  be  adopt- 
ed into  general  practice,  it  would  require  constantly  a  serious 
load  of  metal  for  the  poor  accoucheur  to  cai'ry  into  the  bed-room 
of  his  patient,t  or  run  the  risk  of  losing  his  patient,  if  these  are 
the  only  means  to  be  relied  on. 

1124.  We  should  place  also  under  the  same  ban,  the  lately  re- 
ne\yed  expedient  of  "  transfusion."  We  do  not  hesitate  to  credit 
the  accounts  of  women  not  dying  when  this  scheme  has  been  re- 
sorted to;  but  we  very  much  doubt  whether  the  patient  would 
have  died  had  it  been  withheld.  We  believe  this  principally  on 
the   following  grounds: — first,  because   women    bear   excessive 

*  The  reason  of  tliis  is  at  once  obvious;  for  should  the  placenta  be  separat- 
ed altogether,  the  liquid  cannot  be  so  applied  to  the  uterine  surface,  as  to  make 
this  organ  perceive  the  impression  of  cold,  and  induce  it  to  contract.  Besides, 
it  seems  admitted,  that  it  is  by  the  uterus  perceiving  u  sensation  of  cold,  that  it 
is  induced  to  contract;  now  it  is  well  known  that  this  can  be  accomphshed  in 
a  much  more  simple  plan;  namely,  by  applying  cold  water  or  ice  to  tlie  abdo- 
men, or  introducing  the  latter  into  the  cavity  of  the  organ. 

t  Dr.  Slop's  bag  would  have  been  very  much  too  small,  ample  as  it  was,  for 
so  much  ingenious  machinery. 
52 


410  UNAVOIDABLE  HEMORRHAGE, 

losses  of  blood  without  death  following ;  second,  because  the  quan- 
tity of  blood  transmitted  to  the  alien  veins  does  not  appear  suffi- 
cient to  prevent  death,  since  but  a  very  few  ounces  have  been 
declared  to  answer;  third,  because  the  additional  quantity  of 
blood,  though  it  increases  by  so  much  the  stock  of  the  patient,  it 
does  not  necessarily  or  contingently  promote  the  tonic  contrac- 
tion of  the  uterus,  without  which,  all  "  appliances  and  means  to 
boot,"  will  be  found  unavailing;  fourth,  because  we  have  never 
yet  met  with  a  case  in  which  the  dormant  powers  of  the  uterus 
could  not  be  roused  into  successful  action,  if  means  were  timely 
employed;  were  of  a  suitable  kind;  and  were  proper!)'  applied. 
All  these  plans  appear  to  us  to  savour  too  much  of  the  improve- 
ments of  Sir  Abel  Handy.* 

1125.  The  cases  related  by  Mr.  Waller,  are  as  strongly  mark- 
ed as  any  perhaps  that  have  met  the  public  eye;  yet  to  us  they 
are  by  no  means  conclusive.  We  can  find  in  Rigby,  Leroux, 
La  Motte,  JNIauriceau,  «Scc.  &e.  cases  equally  formidable,  where 
recoveries  took  place  without  this  means.  And  if  we  dared  to 
enforce  the  above  opinion  by  observations  of  our  own,  we  could 
certainly  relate  a  number  of  cases,  where  the  subjects  of  them 
were  reduced  to  as  great  extremity  as  those  furnished  by  Mr. 
W'aller — we  shall  however  only  refer  to  the  one  related  in  a  sub- 
sequent part  of  this  article;  though  many  equally  formidable,  and 
equally  successful,  could  be  furnished. 

1126.  There  appears  to  be  excited,  at  the  present  time,  a  pas- 
sion for  novelty  in  the  treatment  of  uterine  haemorrhage;  but  no 
remedy  or  means  that  has  hitherto  reached  our  knowledge,  ap- 
pears to  have  any  decided  efficacy  in  themselves,  in  arresting  this 
discharge.  Both  thei'apeutical  and  mechanical  agents  are  anx- 
iously sought  after;  and  each  inventor  of  a  new  mode  of  fulfilling 
an  old,  and  never  to  be  deserted  principle,  vaunts  his  supposed 
improvement  with  a  confidence  that  almost  bids  defiance  to  scep- 

*  Handy,  Jr.  demands,  after  Sir  Abel  has  set  the  house  on  fire  by  his  expe- 
viiTieiits,  " Wliat  is  to  be  done?  Where's  your  famous  preparation  for  extin- 
guishing flames?" 

"  Sir  Abel.  It  is  not  mixed." 

"Handy,  Jr.  Where's  your  fire  escape?" 

"  Sir  Abel.  It  IS  not  fixed." 

"Handy,  Jr.  Where's  yom-  fire  engine?" 

"Sir  Mel.  'Tis  on  the  road." — {Speed  the  plough.) 


UNAVOIDAKLF,  HiRMOnnHAOE.  411 

ticism,  until  trial  is  made  of  its  boasted  powers — it  is  then  found 
to  have  no  superiority  over  the  remedial  agents  already  known, 
and  heretofore  relied  upon.  In  all  these  attempts  it  appears  to  be 
forgotten,  that  the  only  indication  in  a  threatening  haemorrhage 
after  the  delivery  of  the  child,  is  to  procure  the  tonic  contraction 
of  the  uterus;  yet,  some  of  the  means  had  recourse  to,  are  but  ill 
calculated  for  this  end.  Of  this  kind,  is  "  transfusion;"  the  "  fdl- 
ing  of  the  uterus  with  rags;"  "  the  compression  of  the  aorta;" 
''injecting  the  umbilical  vein,"  &c.  &c.  And  the  therapeutical 
means,  such  as  the  introduction  of  vinegar,  or  the  acid  of  lemons, 
have  no  other  power  perhaps  upon  the  flaccid  uterus,  than  as  a 
kind  of  vehicle  to  the  mechanical  agents,  if  we  may  so  express  it; 
and  a  variety  of  these  can  unquestionably  be  employed  with  at 
least  equal  success  without  their  assistance.  Yet  we  hold  it  pro- 
per to  lay  before  the  inexperienced  practitioner  all  the  means 
which  have  of  late  challenged  the  attention  of  the  medical  pub- 
lic. Therefore,  with  this  impression  upon  us,  we  shall  relate 
several  other  schemes,  on  which  the  changes  have  been  rung  with 
much  complacency  in  our  various  periodical  Journals. 

1127.  Messrs.  Gorat,  Evrat,  &c.  propose  the  immediate  appli- 
cation of  the  citric  aid  to  the  internal  surface  of  the  uterus,  with 
a  view  to  arrest  haemorrhage  after  delivery.  They  describe  this 
method  in  the  following  terms:  they  strip  a  lemon  of  its  skin, 
and  having  cut  one  end  of  it,  they  carry  it  into  the  uterus,  and 
then  express  the  juice  on  the  sides  of  the  cavity.  They  allow 
the  decorticated  lemon  to  remain,  until  the  irritation  produced  by 
the  juice,  and  this  foreign  body,  excites  the  uterus  to  contraction 
which,  constringing  the  tissue  of  that  organ,  stops  the  hemor- 
rhage, and  the  lemon  is  expelled  with  the  coagulum  formed 
about  it.* 

112S.  This  is  one  of  the  late  improvements  in  the  treatment  of 
this  formidable  complaint,  and  to  which  we  have  just  alluded. 
It  will  be  in  most  instances,  in  this  country  at  least,  in  the  same 
predicament  as  several  of  the  means  we  have  already  noticed — 
rarely  at  hand  when  required.  It  will  also  be  seen,  that  from 
the  mode  of  its  application  it  acts  but  as  a  mechanical  stimulant 
upon  the  uterus;  and  we  are  disposed  to  believe  in  no  manner 
superior,  or  more  certain  than  the  naked  hand,  so  very  many 


*  Anderson's  Quarterly  Journal,  Vol.  II.  No.  VI.  p.  298.     Revue  Medicate 
&.C.  &c.  &c. 


412  UNAVOIDABLE  HJEMORRHAGE. 

years  recommentled.  For  in  an  hremorrliage  that  would  require 
manual  interference,  Ave  are  of  opinion  that  the  small  quantity  of 
acid  which  could  be  expressed  within  the  uterus,  would  be  so  ef- 
fectually and  suddenly  diluted  by  influent  blood,  as  to  render  its 
powers  altogether  nugatory.  Now  we  know  from  experience, 
that  the  very  presence  of  a  foreign  body  within  the  cavity  of  the 
uterus,  and  this  passed  perhaps  even  somewhat  rudely  over  its 
surface,  will  cause  it  to  contract,  and  thus  arrest  the  discharge; 
and  this  mechanical  influence  has  been  acknowledged  for  more 
than  a  century.  For  we  perfectly  disclaim  all  efiects  from  the 
acid;  and  for  the  reason  just  stated:*  and  we  cannot  but  regard 
the  suggestion  of  M.  Gorat,  &c.  as  one  of  those  determined  at- 
tempts at  novelty  which  a  little  subsequent  experience  will 
cure. 

1129,  A  woman  aged  thirty -two,  was  taken  in  labour  with  her 
first  child,  on  the  12th  of  February,  1825.  The  pains  soon  ceased, 
and  on  the  15th,  M.  Bedel,  physician  at  Schirmack,  was  consult- 
ed, who  speedily  delivered  her  with  the  forceps  of  a  dead  child. 
The  haemorrhage  was  so  considerable  as  to  render  the  immediate 
removal  of  the  placenta  necessary;  but  the  uterus  did  not  con- 
tract, and  the  bleeding  continued,  together  with  tremblings,  syn- 
cope, cold  sweats,  &c-  Irritation  on  the  internal  surface  of  the 
uterus,  cold  water  to  the  abdomen,  injections  into  the  uterus  of 
cold  water  and  vinegar,  were  unavailing. 

1130.  Plugging  the  vagina,  and  also  the  uterus,  were  now  re- 
sorted to,  as  the  only  remaining  means  of  safety.  The  uterus 
was  filled  with  pieces  of  rags,  for  fear  the  patient  could  not  sus- 
tain the  loss  of  blood  necessary  to  fill  the  cavity;  while  a  methodic 
compression  was  at  the  same  time  made  upon  the  abdomen.  The 

*  In  addition  to  what  we  have  urged  above,  against  the  agency  of  the  acid 
producing  any  effect  from  its  own  properties,  it  may  be  added,  that  in  such  hse- 
morrhages  as  occur  before  the  entire  separation  of  the  placenta,  the  whole,  or 
very  near  the  whole,  of  the  internal  surface  of  the  uterus,  is  still  lined  by  the 
membranes;  and  consequently  the  acid  cannot  be  placed  in  contact  with  the 
uterine  fibre:  therefore,  if  any  effect  follow  the  introduction  of  the  lemon  under 
such  cu-cunistanccs,  it  must  proceed  from  its  mechanical  irritation,  aided  by  that 
of  the  hand.  Besides,  the  author  of  this  method  of  treating  uterine  haemori'hage, 
lays  stress  upon  the  sudden  ejection  of  the  citric  acid  by  the  pressui-e  of  the 
hand;  but  Chaussier  tells  us,  in  pressing  a  lemon  cut  as  directed,  and  squeezed 
very  tightly,  it  will  not  throw  out  its  liquor  in  streams  as  stated  by  the  inven- 
tor. At  all  events,  it  is  no  improvement  upon  tlie  sponge  and  strong  vinegar, 
Jong  since  recommended  for  the  same  purpose. 


UNAVOIDABLE  HiEMORKHAGE.  413 

haemorrhnge  was  immediately  arrested,  and  soon  after  reaction 
ensued. 

1131.  On  the  16th,  JNIr.  Bedel  removed  the  plugs  from  the  ute- 
rus cautiously  and  successively :  and  had  the  pleasure  to  find  the  ute- 
rus to  contract  regularly  after  each  removal.  The  lochial  discharge 
continued:  but  there  was  no  secretion  of  milk.  The  patient  re- 
covered slowly.* 

1132.  This  is  another  instance  of  attempting  to  arrest  an  alarm- 
ing uterine  haemorrhage  in  a  new  way  ;  but  it  more  strong- 
ly recommends  itself  to  us  than  some  others,  from  its  having  suc- 
ceeded in  the  instance  in  which  it  was  tried,  and  from  the  sim- 
plicity of  its  plan,  and  the  certainty  of  the  materials  to  operate 
with  being  almost  always  at  hand.  But  we  cannot  help  feeling 
surprised,  that  we  do  not  find  an  instance,  among  those  we  have 
recorded,  in  Vv'hich  well-directed  and  properly  continued  fric- 
tions over  the  region  of  the  uterus  have  been  instituted;  a  means, 
which  has  ever,  in  our  hands,  proved  certain  in  restoring  the  lost 
energy  of  the  uterus.  Nor  is  there  any  case  related,  within 
our  knowledge,  out  of  this  country,  in  which  the  acetate  of  lead 
has  been  given  in  proper  doses;  nor  in  which  the  ergot  had  been 
recoursed  to,  until  very  lately,  though  the  success  of  these  drugs 
in  uterine  haemorrhage  have  been  frequently  proclaimed  in  the 
periodical  journals  of  this  country  for  at  least  the  last  eight 
years. 

1133.  Nor  are  we  less  surprised  at  the  misapprehension,  which 
almost  constantly  seems  to  prevail,  as  regards  the  use  of  the  tam- 
pon in  the  cases  under  consideration;  for  it  is  to  the  ill-timed 
application  of  this  remedy,  that  we  must  attach  its  want  of  suc- 
cess. Leroux  does  not  propose  this  plan  as  certain  of  success  in 
floodings  which  follow  the  expulsion  of  the  placenta;  though  he 
declares  he  has  succeeded  sometimes  with  it  in  such  cases.  Its 
great  value  is  in  floodings  before  impregnation;  before  the  uterus 
is  emptied,  when  it  is  impregnated;  and  when  this  organ  will 
contract,  after  labouj-  is  terminated. 

1134.  In  entering  upon  this  part  of  our  subject,  it  will  be  im- 
portant to  the  consideration,  that  we  say  a  few  words  upon  the 
changes  effected  in  the  uterus  itself,  by  the  delivery  of  the  child, 
and  the  expulsion  of  the  placenta. 

•  Bulletin  Universal,  for  January,  1826,  from  the  Gazette  de  Sante,  for  De- 
cember, 1825. 


414  UNAVOIDABLE  HiRMORRIIAGE. 

1135.  I  regard  the  uterus  as  a  hollow  muscle;  and,  like  the 
other  hollow  muscles,  has  no  separate  or  independent  antago- 
nizing form;  but  has,  like  them,  a  compensating  one,  arising 
from  its  own  organization  or  structure;*  and  also,  like  all  the 
muscles  of  this  kind,  when  not  distended  by  some  distracting 
force,  will  contract  by  virtue  of  some  power  of  its  own,  and  upon 
the  healthy  disposition  of  this  kind  in  the  uterus  does  the  wel- 
fare of  the  woman  depend,  in  every  instance  of  child-birth  or 
abortion. 

1136.  I  shall  not  stop  to  inquire,  as  its  consideration  is  not  im- 
mediately involved  in  the  present  investigation,  whether  this  is 
a  legitimate  muscular  contraction,  or  the  exertion  of  that  power, 
common  to  many  organic,  as  well  as  inorganic  substances,  termed 
elasticity.  My  own  opinion,  however,  is  decidedly  made  up,  that 
the  efforts  the  uterus  makes  to  expel  its  contents,  and  to  close  it- 
self after  it  has  performed  this  office,  is  by  virtue  of  a  genuine 
muscular  contraction. 

1137.  In  the  performances  of  these  offices,  two  distinct  powers 
are  concerned.  One  shows  itself  by  a  constant  disposition  to  lessen 
the  cavity  of  the  uterus,  whenever  it  may  be  put  upon  the  stretch; 
or  at  least,  whenever  the  cause  is  removed,  that  placed  it  in  that 
condition.  The  other  declares  itself  by  alternate  contrajction, 
which  is,  perhaps,  only  an  exalted  degree  of  the  same  power, 

•  I  say,  that  the  uterus  has,  like  the  heart,  and  perhaps  all  other  hollow  mus- 
cles, an  antagonizing  power  within  itself,  and  this  by  its  own  organization.  I  shall 
attempt  to  pro^e  this,  by  stating,  that  in  consequence  of  that  contraction,  which 
we  call  the  alternate  contraction  of  the  uterus,  having  taken  place,  a  considera- 
ble portion  of  the  blood  which  at  that  moment  occupied  the  uterus,  is  driven 
quaqud  versum  into  the  general  system;  a  facility  for  which  is  derived  from  the 
frequent  anastomoses  of  the  arteries  and  veins,  and  by  the  latter  not  having 
valves.  This  is  pi-oved  by  the  diminished  thickness  of  the  uterine  parietes,  and 
by  the  whole  surface  of  this  organ  becoming  paler  at  the  moment  of  contraction. 
This  state  of  things  continues  until  tliis  effort  has  ceased — so  soon  as  this  hap- 
pens, (which  may  be  longer  or  shorter,  according  to  the  power  wliich  governs 
the  contraction,  and  the  state  perhaps  of  the  musciJar  fibres  of  the  uterus  itself,) 
the  vessels  which  had  just  been  deprived  of  a  portion  of  their  contents  by  the 
contraction,  will  at  the  moment  of  relaxation  be  but  imperfectly  filled,  and  even 
a  genuine  vacuum  may  be  induced;  but,  so  soon  as  the  restraint  imposed  upon 
the  whole  of  the  uterine  vessels  by  this  contraction  is  taken  off;  the  blood  will 
instantly  rush  into  them,  to  restore  the  disturbed  equilibrium,  and  thus  again 
distend  these  vessels;  which  distention  will  prove  a  stimidus  to  the  uterine  fi- 
bres, and  thus  induce  a  new  conti-action :  and  in  this  way  would  I  account  for 
'the  alternate  pains  of  labour. 


UNAVOIDABLE    IliEMOUKHAGE.  415 

when  urged  by  stimuli,  as  in  child-birth,  abortion,  or  from  any 
other  circumstances  which  may  require  its  interference,  to  expel 
a  foreign  body  from  its  cavity. 

1138.  The  first  of  the  powers  just  noticed,  has  been  termed 
"  tonic  contraction;"  and  the  second  "spasmodic  contraction," 
from  its  being  usually,  though  not  necessarily,  attended  with  pain. 
This  Tatter,  it  must  be  remembered,  cannot  take  place  without 
the  former  having  preceded  it:  though  the  former  can  happen 
without  the  latter.*  (251,  252.) 

1139.  Now  the  economy  of  the  uterus,  in  its  healthy  condition 
is  such,  that  it  immediately  exerts  its  tonic  force  to  close  upon, 
and  to  accommodate  itself  to  the  exact  size  and  shape  of  such 
contents — thus,  soon  as  the  liquor  amnii  is  discharged,  the  ute- 
rus instantly  diminishes  its  size,  by  virtue  of  this  tonic  power,  and 
this  in  the  exact  proportion  to  the  quantity  of  water  displaced; 
and  so  plastic  is  this  power,  that  it  makes  the  parietes  of  the  ute- 
rus assume  the  inequalities  presented  by  the  surface  of  the  child; 
and,  when  the  child  is  delivered,  it  reduces  itself  so  much  as  to 
compress  the  placenta,  and  force  it  from  its  attachment;  and 
eventually  expels  it  from  its  cavity;  when  this  is  achieved,  it  goes 
on  reducing  itself,  until  it  interrupts,  in  a  great  measure,  the  sup- 
ply of  blood  from  the  spcrmatics  and  hjqiogastrics;  closes  almost 
completely  the  mouths  of  the  vessels  exposed  by  a  separation  of 
the  placenta,  and  thus  prevents  any  inordinate  flow  of  blood. 

1140.  From  this  it  appears,  that  the  safety  of  the  woman  de- 
pends almost  entirely  upon  the  healthy  exercise  of  the  power  just 
termed  the  "tonic  contraction;"  and  on  the  contrary,  that  the 
risk  she  may  run  in  giving  birth  to  her  child,  is  in  exact  propor- 
tion to  the  diminished  force  of  this  power;  of  course,  the  prevent- 
ing and  stopping  of  floodings,  will  depend  upon  recalling  it  when 
absent,  or  upon  augmenting  it  when  deficient. 

1141.  The  tonic  power  of  the  uterus  may  be  feeble,  or  altogether 
wanting — it  may  be  lost  in  every  portion  of  the  uterus,  or  only  in 
a  part;  thus  the  fundus  may  possess  it,  and  it  may  be  absent  from 
the  body  and  neck;  this  may  give  rise  to  the  diversion  of  the  ute- 
rus— the  fundus  and  neck  may  be  deprived  of  it,  while  the  body 
may  enjoy  it — this  may  occasion  the  hour-glass  contraction;  the 
body  and  fundus  may  be  exhausted  of  it,  while  the  neck  retains 

*  See  Essay  on  the  means  of  lessening-  pain  in  certain  cases  of  labour,  &c.  by 
the  author. 


416  HEMORRHAGE,   REFORE 

it — this  may  produce  the  concealed  hremorrhage.  The  body  and 
fundus  may  be  firmly  contracted,  while  the  neck  of  the  uterus  may 
be  flaccid — this  may  occasion  flooding,  if  the  placenta  has  been 
attacked  in  that  vicinity. 

Sect.  VL — 6.  Causes  of  Uterine  Inertia. 

1142.  The  remote  causes  of  uterine  inertia  are  said  by  Leroux 
and  others  to  be — 1st.  A  general  morbid  condition  of  the  body,  as 
tendency  to  scurvy,  &c.  2d.  Long  illness.  3d,  A  depraved  condi- 
tion of  the  circulating  mass.  4th.  Unusual  laxity  of  fibre,  as  in 
leucophlegmatic  habits,  &c.  5th.  Over-distention,  from  an  excess 
of  liquor  amnii.  Gth.  Strong  emotions  or  passions  of  the  mind.  7th. 
A  long  protracted  labour.  8th.  A  previous  haemorrhage.  9th.  Le- 
sions in  the  proper  substance  of  the  uterus  itself 

1143.  But  the  condition  of  the  tonic  power  is  far  from  being 
always  regulated  by  the  contingent  situation  of  the  general  sys- 
tem; we  cannot  infer  its  absence  from  the  debilitated  state  of  the 
body  at  large;  nor  can  we  calculate  upon  its  presence  with  cer- 
tainty, because  every  other  function  is  carried  on  vigorously — 
this  is  a  fact  well  known  to  every  practical  accoucher,  and  should 
teach  us  this  highly  important  caution;  to  act  as  if  this  power 
were,  or  easily  might  be  expended,  and  to  consider  no  woman  safe 
from  the  casualty  of  its  exhaustion,  until  we  are  assured  to  the 
contrary  by  a  careful  examination. 

1 1 44.  Fortunately  for  the  patient,  as  well  as  for  the  practitioner, 
this  power,  when  weakened,  nay,  even  to  excess,  may  almost  al- 
ways be  recalled  by  proper  means,  and  is  almost  certainly  obe- 
dient to  the  judicious  use  of  appropriate  stimuli;  but  upon  the 
time  and  manner  of  this  application  much  will  be  shown  presently. 

Sect.  VII. — 7.  Of  Hxmorr/iagc  before  the  Plnecnta  is  expelled. 

1145.  We  are  now  to  consider  hajmorrhage  as  it  may  occur, 
before  the  placenta  is  expelled.  It  must  be  recollected  that  a 
flooding  cannot  happen,  but  when  the  placenta  is  in  part,  or 
wholly  separated  from  the  uterus;  and  that  this  separation  has 
been  efiected  in  the  cases  we  arc  now  to  speak  of,  by  uterine 
contraction;  unless  a  sufficiently  powerful  mechanical  cause  had 
been  previously  offered.  For  so  long  as  the  placenta  preserves 
its   continuity  entire   with  the  uterus,  no  flooding  can    ensue, 


THE  PLACENTA  IS  EXPELLED.  417 

should  this  viscus  be  even  in  a  stale  of  complete  atOny  or  exhaus- 
tion.* 

1146.  As  there  is  considerable  variety  in  these  cases,  it  will  be 
well  for  the  sake  of  perspicuity  to  consider  them  under  the  fol- 
lowing heads: 

a.  1st.  Where  there  is  a  partial  separation  of  the  placenta,  but 
the  uterus  enjoying  some  tonic  power. 

b.  2d.  Where  there  is  a  partial  separation,  but  the  uterus  pos- 
sessing very  little  or  no  tonic  power. 

c.  3d.  Where  there  is  a  partial  separation  of  the  placenta,  while 
the  remaining  portion  is  too  adherent,  and  the  uterus  con- 
tracts but  feebly. 

*  Unless  some  mechanical  violence  has  been  done  to  the  uterus,  either  from 
external  impression,  or  from  some  incautious  manoeuvre  performed  within  its 
cavit}^,  as  in  the  act  of  turning-,  or  tlie  injudicious  use  of  instruments,  the  placenta 
will  preserve  its  connection  with  the  uterus  until  disturbed  by  uterine  contrac- 
tions; and  consequently  there  will  be  an  exemption  from  flooding,  until  this 
takes  place;  but  this  connection  may  be  destroyed  in  a  moment,  by  the  causes 
just  stated,  aud  an  hemorrhage  as  quickly  follow. 

Since  writing  the  above  note,  an  interesting  case  has  occurred,  which  com- 
pletely proves  my  position.     Mrs. ,  on  the  23d  of  March,  1823,  was  taken, 

at  her  full  period,  with  slight  pains,  and  the  other  marks  of  approaching  labour. 
Soon  after  these  had  manifested  themselves,  she  was  seized  with  violent  vomit- 
ing', and  considerble  hemorrhage:  there  was  an  almost  constant  effort  in  the 
uterus  to  throw  off  its  contents,  togetlier  with  an  occasional  increase  of  pain. 
I  was  now  sent  for,  and  found  the  patient  as  above  stated.  The  vomiting  re- 
turned from  time  to  time;  and  whenever  it  did  so,  there  was  an  Increase  of  the 
heemorrhage;  and  tliis  also  occurred  when  the  alternate  pains  were  on,  which 
gave  rise  to  a  suspicion  that  it  was  a  placental  presentation.  I  ordered  the  pa- 
tient to  her  bed;  and  upon  examination,  the  membranes  were  found  protruding, 
and  the  child  rapidly  advancing.  I  ruptured  the  membranes  immediately,  and 
the  hemori-hage-  was  instantly  suspended:  in  a  few  minutes  more  the  child  was 
expeUed,  but  still-born,  Tiie  navel-string  was  cut,  but  not  a  di"op  of  blood  is- 
sued from  either  portion  of  it.  Every  effort  was  unavaillngly  made  to  resusci- 
tate the  child.  The  placenta  was  found  loose  in  the  vagina,  and,  upon  examin- 
ing its  surface,  it  was  found  covered  over  its  whole  extent,  witli  a  thin  black  co- 
agulum;  an  evidence  it  had  been  entirely  separated,  and  the  child  made  to 
perish  in  consequence.  The  uterus  appeai-ed  to  contract  well,  and  everything 
was  promising,  for  an  hoiu";  at  the  expiration  of  this  time,  the  uterus  relaxed, 
and  a  profuse  discharge  instantly  took  place.  When  I  arrived,  (for  I  had  taken 
my  leave,)  tlie  patient  was  very  faint,  extremely  sick  at  stomach,  and  very 
restless,  wliich  necessarily  augmented  the  discharge.  I  immediately  commenc- 
ed pretty  brisk  frictions  upon  the  abdomen — the  uterus  soon  contracted,  and 
did  not  again  relax.  Two  grains  of  opium  were  ordered  every  two  hours,  until 
the  patient  should  become  tranquil.  On  the  following  morning  she  was  found 
much  recruited,  and  had  no  unpleasant  symptom  afterwai-ds. 
53 


418  HiEMORRHAGE,  BEFORE 

d.  4th.  Where  everything  is  as  -at  3d,  except  that  the  uterus 
enjoys  its  full  power. 

e,  5th.  Where  there  is  an  entire  or  partial  separation,  but  the 
uterus  in  a  state  of  exhaustion  or  syncope. 

/.'  6th.  Where  there  is  either  a  partial  or  complete  separation 
of  the  placenta,  and  where  the  body  and  fundus  are  in  a 
state  of  inertia;  while  the  neck  enjoys  its  tonic  power. 

a.  I. —  Where,  there  is  a  partial  separatioji  of  the  Placenta,  but 
the  Uterus  enjoying  some  tonic  j)Ower. 

1147.  In  this  case  the  last  efforts  of  the  uterus  to  expel  the 
child  may  have  occasioned  a  partial  separation  of  the  placenta, 
and  of  course  there  will  be  a  greater  or  less  discharge  of  blood: 
1st.  As  the  exposed  surface  may  be  large  or  small.  2d.  As  the 
contractile  power  of  this  organ  may  be  more  or  less  perfect.  3d. 
As  the  circulation  of  the  blood  may  be  more  or  less  hurried. 

1148.  In  almost  every  instance  after  the  birth  of  the  child,  we 
find  a  quantity  of  blood  issue  from  the  vagina;  but  the  young 
practitioner  must  not  look  upon  this  as  an  hemorrhage,  unless  it 
continue  some  time  and  has  an  evident  effect  upon  the  pulse.* 
In  this  case,  he  is  immediately  to  attempt  to  arrest  it,  by  solicit- 
ing an  inci-eased  contraction  of  the  uterus,  by  pretty  briskly 
passing  his  hand  over  the  region  of  the  uterus,  and  from  time  to 
time  attempting,  as  it  were,  to  grasp  the  uterus  by  closing  his 
fingers  upon  it. 

1149.  By  proceeding  in  this  manner,  he  will  almost  instantly 
find  the  uterus  harden  under  his  hand;  a  coagulum  of  a  greater 
or  less  size  will  escape  from  the  os  externum;  a  slight  pain  may- 
come  on,  and  the  placenta  may  be  thrown  down  into  the  vagina. 
When  this  contraction  takes  place,  as  it  almost  alwaj-s  does, 
when  the  woman  has  not  been  too  much  exhausted  either  by  a 
long-protracted  labour,  or  by  disease,  the  discharge  of  blood  is 
quickly  put  a  stop  to;  the  uterus  diminishes  much  in  size,  and 
retires  almost  within  the  pelvic  cavity,  while  the  placenta  is  en- 

*  Some  women  will  bear  a  much  greater  loss  of  blood  than  others;  and, 
therefore,  we  are  to  decide  upon  the  propriety  of  interference,  from  the  effect 
which  tills  loss  has  upon  the  system,  ratlier  than  from  the  quantity  which  has 
been  expended.  If  w"e  do  iiot  attend  to  this  rule,  we  shall  interfere  unneces- 
sarily where  the  powers  of  the  system  are  everyway  competent  to  the  ex- 
igencies; and  in  other  cases  we  may  delay  assistance  so  long  as  to  render  it 
unavailing. 


THE  PLACENTA  IS  EXPELLED.  419 

tirely  detached  from  the  uterus,  or  it  may  even  be  expelled  from 
the  vagina.  This  is,  perhaps,  the  most  simple  case  of  flooding 
that  can  occur,  and  I  believe  it  never  requires  any  other  manage- 
ment than  frictions  upon  the  abdomen;  its  termination  may  not 
always  be  so  sudden  as  I  have  now  stated,  but  it  is  sure  to  take 
place  in  a  very  short  time,  and  as  fortunately  as  I  have  described 
it  to  do. 

b.  II. —  Where  there  is  a  partial  separation,  but  the   Uterus 
2J0ssessing  very  little  or  no  tonic  jjower. 

1150.  In  this  case,  the  same  cause  may  produce  the  same  ef- 
fects as  in  I.  :  but  the  uterus  may  be  in  a  very  different  condition; 
here  there  will  not  only  be  a  discharge  of  blood  in  proportion  to 
the  surface  exposed  by  the  separation  ofthe  placenta  and  the 
state  of  the  circulation,  but  also  a  continuance  of  it,  commensu- 
rate with  the  atonic  condition  of  the  uterus. 

1151.  This  state  may  continue  for  a  longer  or  a  shorter  time 
according  to  the  force  of  the  remote  cause  which  induced  the 
atonic  state  ofthe  uterus,  or  as  it  may  be  of  easy,  or  of  difficult 
removal. 

1152.  In  this,  like  every  other  case  of  flooding  at  this  period, 
we  should  endeavour  as  quickly  as  possible,  1st.  To  remove  the 
cause  which  induced  the  atonic  state  of  the  uterus,  wherever  it 
is  evident  and  practicable.  2d.  To  excite,  as  soon  as  may  be, 
uterine  contraction.  It  will  be  readily  perceived,  that  we  can- 
not control  some  of  the  remote  causes  of  inertia  just  enumera- 
ted, and  therefore,  our  chief  attention  should  be  directed  to  the 
fulfdment  of  the  second;  and  this  should  be  immediately  attempt- 
ed by  frictions  upon  the  abdomen,  as  above  directed.  On  fric- 
tions I  have  the  greatest  reliance;  and  I  never  fail  to  employ 
them,  with  a  view  to  promote  contraction,  whether  there  be 
haemorrhage  or  not,  provided  the  uterine  globe  be  not  felt  firm 
upon  the  application  of  the  hand  to  the  abdomen  immediately 
after  the  child  is  removed  from  the  mother;  and  wben  there  is  a 
flooding,  I  chiefly  rely  upon  them,  to  restore  the  energy  of 
the  uterus;  and  in  this  I  never  have  been  disappointed — its  in- 
fluence is  as  prompt  as  it  is  efficacious;  indeed,  I  consider  fric- 
tions as  indispensable,  let  whatever  other  means  be  emploj^cd. 

1153.  I  have  never  had  the  misfortune  to  meet  with  a  uterus 
that  w^as  altogether  insensible  to  this  mechanical  stimulus;  nor  to 
lose  a  patient  from  the  immediate  loss  of  blood;  and  I  can  with 


420  HiEMORRHAGE,  BEFORE 

great  truth  affirm,  that  this  simple  plan  has  constantly  appeared 
to  me  to  be  the  chief  agent  in  arresting  the  most  formidable  flood- 
ings  of  the  kind  I  am  now  considering.  The  external  face  of  the 
uterus,  when  acted  upon  by  the  hand  through  the  abdomnial 
parietes,  appears  to  me  to  be  equally  sensible  to  stimuli  of  the 
mechanical  kind,  as  ^he  internal  surface;  and  it  certainly  offers 
facilities  and  advantages  that  the  cavity  does  not: — 1st.  It  is 
always  accessible  to  be  acted  upon ;  2d.  No  risk  is  run  by  very 
freely  stimulating  it  with  the  extremities  of  the  fingers ;  3d.  It 
excites  very  little,  or  no  pain,  if  judiciously  managed;  4th.  No 
fear  is  to  be  apprehended  of  increasing  the  discharge,  which  is  not 
always  the  case,  when  the  hand  is  employed  within  the  uterine 
cavity ;  5th.  No  danger  of  inducing  inflammation  or  other  injury 
as  may  happen  by  the  introduction  of  the  hand. 

1154.  The  attempt  to  arrest  haemorrhage,  by  reviving  the 
powers  of  the  uterus  is  not  new — it  was  long  since  recommended 
by  a  Mons.  Basse*  an  accoucheur  of  Paris,  whose  method,  though 
I  do  not  exactly  follow  it,  I  will  give  in  his  own  words.  "  II  ne 
faut  que  porter  les  deux  mains  sur  la  region  hypogastrique,  et 
comprimer  mollement  le  corps  de  la  matrice  par  un  mouvement 
tantot  circulaire,  tantfit  de  droite  a  gauche,  de  gauche  a  droite,  de 
haut  en  has  et  de  has  en  haut.  Tons  ces  differens  mouvemens 
sont  absolument  necessaires,  a  cause  des  differens  plans  de  fibres 
que  s'entrecroisent  et  forment  une  espece  de  reseau." 

1155.  I  have  just  observed,  that  I  do  not  exactly  follow  his 
method ;  though  the  effect  is  precisely  the  same — one  hand  is  all 
that  is  necessary,  or  that  can  be  conveniently  employed;  and  if 
this  be  industriously  and  properly  used,  I  am  persuaded  that  it 
will  rarely  fail.  I  must,  however,  in  justice  to  myself  declare,  I 
was  in  the  habit  of  employing  this  method  long  before  I  was 
aware  it  had  been  previously  recommended  by  M.  Dasse. 

1156.  When  we  have  adopted  this  method  we  are  to  take  care 
we  do  not  abandon  it  too  soon  ;  for  it  is  not  sufficient  that  we  pro- 
cure the  contraction  of  the  uterus;  we  must  maintain  it  in  this 
condition  for  some  time,  and  this  by  the  continuance  of  the  fric- 
tion. And  I  would  at  this  time  caution  the  inexperienced  prac- 
titioner, against  a  very  natural  cause  of  alarm;  when  almost  at 
the  instant  he  feels  the  uterus  hardening  and  diminishing  under 
his  hand,  he  hears  very  distinctly  a  considerable  discharge  of  coa- 

*  Joui-nal  des  Savan's  d'Aout,  1792,  p.  47'4. 


THE  PLACENTA  IS  EXPELLED.  421 

gula  and  fluid  pass  from  the  vagina;  and  at  the  same  moment  he 
finds  the  uterus  retiring  as  it  were  from  under  his  hand. 

1157.  This  discharge  is  but  the  effect  of  the  contraction  induc- 
ed by  his  manoeuvres  upon  the  external  surface  of  the  uterus,  and 
must  be  regarded  as  a  favourable  omen,  as  it  assures  us  that  the 
uterus  is  about  to  regain  its  powers.  Perseverance  is  now  all-im- 
portant; the  frictions  are  to  be  continued  until  he  has  sufficient 
evidence  of  the  permanency  of  the  contraction,  by  noting  that  the 
uterus  no  longer  relaxes  itself,  as  it  did  most  probably  at  the  com- 
mencement of  his  operations. 

1158.  Should  this  plan,  however,  not  succeed  in  detaching  the 
placenta,  and  stopping  the  flooding,  we  are,  secondl3'-,.to  deliver 
the  placenta  by  the  introduction  of  the  hand  within  the  cavity  of 
the  uterus,  as  this  mass  must  now  be  considered  as  the  cause  of 
the  continuance  of  the  hsemorrhage,  by  preventing  the  uterus  from 
contracting  sufficiently  to  shut  up  the  mouths  of  the  bleeding  ves- 
sels. It  will  be  found  either  partially  or  entirely  detached  ;  if  in 
the  first  condition,  we  insinuate  carefully  the  fingers  behind  the 
loose  portion  of  the  placenta,  and  gently  separate  the  adhering 
part ;  we  then  grasp  the  mass  in  the  hand,  and  rotate  it  several 
times  against  the  internal  face  of  the  uterus,  with  a  view  of  more 
certainly  procuring  subsequent  contraction;  nor  must  the  hand  be 
withdrawn  until  this  is  perceived — should  the  uterus,  however, 
be  found  to  contract  firmly  upon  the  hand  immediately  after  it  has 
effected  the  separation  of  the  placenta,  it  may  be  gradually,  but 
never  suddenly  withdrawn.* 

1159.  If  the  placenta  be  found  detached  from  the  uterus,  it 
must  be  withdrawn  ;  but  the  same  precautions  should  first  be 
practised.  We  must  not,  however,  consider  the  patient  free 
from  all  risk,  because  the  placenta  is  extracted ;  we  should  ex- 
amine the  condition  of  the  uterus,  by  again  placing  the  hand  upon 
the  abdomen;  if  it  be  well  contracted,  it  will  be  found  hard  and 
about  to  sink  within  the  pelvic  cavity,  which  will  give  us  strong 
grounds  to  believe,  that  the  woman  is  about  to  do  well;  but  if, 
on  the  contrary,  the  uterus  is  found  large  and  not  very  firm,  we 
have  every  reason  to  fear  there  will  be  a  renewal  of  the  flooding, 
and  the  frictions  must  again  be  had  recourse  to, 

11  GO,  It  must  be  confessed,  however,  that  the  young  practi- 

*  If  the  utei'us  reg-ain  its  wonted  powers,  the  hand,  with  the  placentaiy  mass, 
will  be  expelled  almost  immediately  from  its  cavity^  but  even  when  this  effect 
is  perceived,  the  hand  sliould  not  be  permitted  to  leave  it  too  suddenly. 


422  HJEMORRHAGE,  BEFORE 

tioner  may  not  be  able,  without  some  further  directions,  to  detect 
the  flaccid  condition  of  the  uterus,  though  he  may  be  ver}^  able  to 
perceive  a  contracted  one — I  shall,  therefore,  state,  that  when 
the  uterus  is  not  contracted,  the  whole  abdomen  appears  equally 
soft  and  pliant — if  the  extremities  of  the  fingers  be  pressed  back- 
ward from  the  pubes,  no  hard  unyielding  tumour  is  perceived; 
and  if  he  inquire  into  the  state  of  the  discharges  from  the  vagina, 
he  will  find  them,  if  not  profuse,  more  abundant  than  they  should 
be — when  all  these  circumstances  combine,  he  may  be  certain 
the  uterus  is  in  a  state  of  inertia  ;  and  he  will  soon  be  convinced 
of  this,  after  he  has  commenced  the  friction  upon  the  abdomen, 
(and  which  should  be  immediately  done,)  by  finding  it  to  harden, 
sometimes  suddenl}^,  at  others  gradually,  under  his  hand,  and  pre- 
sently retire,  when  well-conditioned,  into  the  pelvis,  or  at  least 
the  fundus  will  be  found  below  the  umbilicus. 

1161.  In  all  cases  of  severe  flooding  of  this  kind,  I  am  in  the 
habit  of  directing  the  nurse,  or  any  intelligent  woman,  to  renew 
these  frictions  from  time  to  time  for  an  hour  or  two  after  my  de- 
parture, and  more  especially  should  there  be  a  return  of  dis- 
charge, that  no  evil  may  arise  until  I  can  again  attend  to  the 
patient. 

1162.  3d.  I  think  it  best  to  call  in  every  aid  in  such  cases  that 
may  be  at  command;  and  1  frequently  exhibit  a  few  grains  of 
the  sugar  of  lead,  with  a  pretty  full  dose  of  opium;  repeating  the 
former  v.'ith  a  diminished  dose  of  the  latter,  every  fifteen  minutes 
or  half  hour,  until  I  am  pretty  well  assured  it  will  be  no  longer 
necessary  in  such  crowded  doses — I  however  do  not  give  up  the 
use  of  acetate  of  lead,  unless  the  stomach  be  very  sick,  for  at  least 
twelve  hours,  though  1  diminish  the  quantity.  In  alarming  cases, 
I  first  exhibit  from  five  to  ten  grains  at  a  dose,  unless  contra-in- 
dicated by  the  state  of  the  stomach;  but  when  the  necessity  is 
less,  I  reduce  it  two  grains  every  one,  two  or  three  hours,  as  the 
case  may  require.  Should  much  pain  attend,  I  give  laudanum 
or  opium  until  it  is  relieved  or  much  subdued.  The  ergot,  in 
twenty-grain  doses,  every  twenty  minutes,  should  be  given  in 
this  case;  and  late  experience  seems  to  declare  it  preferable  to 
the  acetate  of  lead,  and  I  now  employ  it  alone. 

1163.  It  is  not  unusual,  where  the  woman  has  sustained  consi- 
derable loss  of  blood,  for  the  stomach  to  become  much  deranged 
— vomiting  or  great  nausea,  is  almost  always  an  attendant  upon 
it ;  and  when  either  takes  place,  it  becomes  very  fatiguing  and 
distressing  to  (lie  patient.     If  she  vomit,  the  exertion  is  so  severe 


THE  PLACENTA  IS  EXPELLED.  423 

as  sometimes  to  exhaust  her  ahnost  to  syncope;  and  during  this 
act,  there  is  almost  always  a  greater  or  less  discharge  of  blood, 
which  at  this  moment  can  be  but  ill  spared — if  it  be  sickness  of 
stomach,  it  renders  the  patient  so  wretched,  that  she  cannot  rest 
quiet  for  a  moment  together  in  one  position;  she  therefore  tosses 
about  from  place  to  place,  until  she  is  almost  spent — I  dread  this 
latter  condition  more  than  an  occasional  effort  to  vomit,  as  it  seems 
to  interrupt  the  tonic  contraction  of  the  uterus,  by  the  influence 
which  nausea  is  wont  to  exert  over  all  muscular  power,  as  well 
as  to  induce  immediate  exhaustion,  by  producing  unceasing  jacti- 
tation. Nothing  tranquillizes  the  stomach  under  these  circum- 
stances, so  far  as  I  have  observed,  like  opium  in  the  solid  form — a 
newly  prepared  pill  of  two  grains  of  the  opium,  with  a  very  small 
portion  of  soap,  to  facilitate  its  solution  in  the  stomach,  should  be 
given  every  hour  or  two,  until  the  vomiting  ceases,  or  the  stomach 
becomes  reconciled.  1  have  foimd  a  sinapism  over  the  region'of 
the  stomach  of  great  service,  and  should  be  resorted  to  if  neces- 
sary. 

1164.  Should  the  discharge  be  too  abundant  after  the  expulsion 
of  the  placenta,  though  not  amounting  to  a  flooding,  it  should  be 
moderated  by  the  use  of  the  sugar  of  lead,  or  ergot;  the  most  effec- 
tual mode  of  exhibiting  the  former,  is  a  watery  solution  of  it  with 
laudanum  in  form  of  an  enema,  unless  the  woman  be  too  weak  to 
have  it  administered  in  this  manner.  The  best  formula,  we  be- 
lieve for  the  injection,  is  the  following: 

R.    Acetate  plumb.  3j. 

Tinct.  Thebiac.      gut.  Ix. 

Aq.  font,  tepid.  5ij.   M.   pro  enema, 

and  the  ergot  in  powder,  may  be  given  in  ten-grain  doses  every 
half-hour,  until  four  or  five  doses  are  taken, 

c.  Ill, —  Where  there  is  a  partial  separation  of  the  Placenta, 
while  the  remaini7ig jjortion  is  too  adherent,  and  the  Uterus 
contracts  but  feebly. 

1165.  A  flooding  maybe  excessive  under  the  circumstances 
mentioned  in  this  variety,  and  considerable  time  may  be  lost  in 
vainly  soliciting  the  extrusion  of  the  placenta  by  frictions  upon 
the  abdomen,  and  efforts  exercised  upon  the  cord,*  before  it  is 

*  Whenever  an  attempt  is  made  to  deliver  the  placenta  by  force  being  applied 
to  the  cord,  great  care  should  be  taken  that  it  be  not  so  great  as  to  separate  the 
fu'^is  from  tliis  mass;  for  if  tliis  occui-,  it  would  be  most  probably  necessary  to 


424  IIJEMORRHAGE,  BEFORE 

suspected  that  this  mass  may  be  too  adherent — it  is  fortunately 
but  of  rare  occurrence,  but  its  management  on  that  account  should 
be  the  better  defined. 

1166.  We  cannot  know  with  certainty,  if  this  complication  ex- 
ist, until  the  hand  be  pressed  into  the  uterus,  and  a  proper  exami- 
nation made  of  the  condition  of  the  placenta;  for  this  case,  as  far 
as  regards  common  symptoms,  resembles  almost  every  variety  of 
retained  placenta,  and  nothing  but  a  strict  search  can  justify  its 
being  pronounced  a  case  of  adherent  placenta.  This  excuse,  I 
am  aware,  is  frequently  employed  to  justify  the  introduction  of 
the  hand  into  the  uterus,  to  bring  away  the  after-birth  by  force, 
when  it  required  but  a  little  more  time,  or  a  little  more  address, 
to  be  delivered  by  the  natural  agents.  We  frequently  hear  young 
practitioners  boast  of  the  difficulties  they  have  encountered  in 
delivering  the  placenta;  but  we  rarely  meet  with  an  experienced 
one,  who  complains  of  the  same  thing. 

1167.  In  this  country,  I  believe,  that  the  adherent  placenta  is 
of  very  rare  occurrence;  while  in  Great  Britain,  or  rather  perhaps 
London,  it  is  comparatively  frequent,  agreeably  to  the  testimony 
of  Dr.  Ramsbotham.* 

1168.  There  is  something  remarkable  in  the  occurrence  of  this 
condition  of  the  placenta,  for  which  we  do  not  pretend  to  account. 
For  we  cannot  well  suppose,  that  a  practitioner  of  so  much  ex- 
perience as  Dr.  Ramsbotham,  and  one  who  seems  to  possess  so 
much  talent  for  observation,  can  have  mistaken  the  nature  of  the 
cases  he  describes,  as  "  too  adherent  placentas."  In  this  country, 
at  least  so  far  as  my  own  experience  will  justify  the  remark,  this 
diseased  condition  of  the  placenta  is  extremely  rare;  not  having 
met  with  more  than  two  or  three  cases  in  more  than  forty  years. 
It  would  also  appear  to  be  of  very  rare  occurrence  in  some  part 
of  Germany,  as  a  Dr.  Seiter  declares  he  had  not  met  with  a  sin- 
gle case,  "  d'adherence  anormale  entrele  placenta  et  I'uterus,"  in 
a  practice  of  twenty  years.  The  cases  supposed  to  be  of  this  kind, 
have  been  simply  instances  of  the  hour-glass  contraction,  (placente 
enchatonne.)t 

inti'oduce  the  hand,  which  sometuTies  creates  to  the  young  practitioner  a  g-ood 
deal  of  embarrassment,  as  the  placenta  is  not  easily  distinguished  from  the  inter- 
nal face  of  the  uterus  itself. — See  Section  on  the  m.ode  of  delivering  the  placenta 
when  the  cord  is  ruptured. 

*  Practical  Observations  on  Midwifery,  page  80,  American  edition. 

f  Sicbold's"  Joui-nal  de  I'Art  des  Accouchements,"  See.  as  quoted  in  "Bul- 
letin des  Sciences  Medicalcs,"  No.  I.Jan.  1827,  p.  83. 


THE  PLACENTA  IS  EXPELLED.  425 

1169.  This  condition  of  the  placenta  may  be  suspected,  when 
the  uterus  continues  large,  though  prett)?^  firmly  contracted;  when 
there  is  a  constant  issue  of  blood,  and  that  florid;  when  the  pla- 
centa is  not  within  reach  of  the  finger;  and  when,  after  a  gentle 
force  is  applied  to  the  cord,  it  is  found  to  retract,  as  if  an  elastic 
string  had  been  stretched.  When  the  quantity  of  blood  expended 
from  the  vagina  would  render  manual  interference  necessary; 
and  more  especially,  when  frictions,  the  exhibition  of  the  sugar  of 
lead,  and  other  "  appliances,"  have  failed  to  stop  the  discharge, 
or  to  expel  the  placenta,  the  hand  should  be  introduced,  and  the 
separated  portion  of  the  placenta  sought  for.  From  this  part  the 
hand  should  take  the  direction  of  the  adhering  portion,  and  if  it 
appear  that  it  would  require  considerable  force  to  destroy  its  con- 
nection with  the  uterus,  every  attempt  to  detach  it  should  be  in- 
stantly desisted  from,  and  only  the  piece  or  pieces  found  loose,  or 
not  adhering,  should  be  removed;  the  remaining  part  must  be 
trusted  to  the  efforts  of  nature. 

1170.  There  will  necessarily  be  a  difference  both  in  degree,  as 
well  as  in  the  extent  of  the  adhesion  in  individual  cases — white 
some  may  be  only  rather  more  strict  than  is  usual,  others  will  seem 
to  have  the  substance  of  the  placenta  identified  with  that  of  the 
uterus — and,  while  a  small  portion  only  may  be  too  adherent  in 
one  case,  a  large  one  may  be  so  situated  in  another.  But  in  every 
instance,  where  there  is  a  separated  portion,  there  will  be  a  dis- 
charge of  blood  from  the  vagina,  either  fluid  or  coagulated;  and 
that,  in  proportion  to  its  accumulation,  or  the  activity  of  the  ute- 
rine fibres.  These  cases  are  almost  always  accompanied  by  pain, 
though  not  of  the  most  severe  kind;  they,  however,  make  but  lit- 
tle impression  upon  fhe  placenta,  nor  do  they  much  diminish  the 
size  of  the  uterus;  yet  with  each  return  there  is  more  or  less  blood 
discharged,  and  the  woman  rendered  faint  by  the  frequency,  ra- 
ther than  the  quantity  evacuated  at  each  contraction,  except 
when  there  is  a  large  portion  separated;  then,  as  in  every  other 
instance,  she  will  be  more  quickly  exhausted. 

1171.  In  cases  like  these,  it  seems  to  be  agreed,  that  nothing 
but  putting  the  uterus  in  a  condition  to  contract,  b}'  the  removal 
of  such  portions  of  the  placenta  as  can  be  readily  detached,  will 
put  a  slop  to  the  flooding,  or  even  moderate  it;  and  it  seems  also 
well  understood,  that  even  this  does  not  place  the  woman  beyond 
danger — the  efforts  of  nature  arc  not  always  availing,  and  the 

54 


426  HEMORRHAGE,   BEFORE 

woman  dies  from  the  mischief  created  by  a  retained  portion  of  the 
placenta. 

1 172.  Should  the  discharge  continue  after  a  part  of  the  placenta 
is  removed;  the  acetate  of  lead,  ergot  and  frictions,  should  be  con- 
tinued; and  astringent  and  detergent  liquors  should  be  thrown 
from  time  to  time  into  the  uterus  itself,  by  means  of  a  proper  sy- 
ringe.* 

1173.  Let  this  case  be  treated  with  what  address  it  may,  it  is 
replete  with  danger  to  the  woman;  she  may  sink  from  the  perti- 
nacity of  the  discharge,  or  succumb  under  fever,  or  other  evils 
excited  by  a  putrif3'ing  placenta.  It  is  no  part  of  my  plan  to  speak 
of  the  subsequent  treatment  of  such  cases;  I  can  with  much  con- 
fidence refer,  for  more  information'  upon  this  head,  to  the  very 
able  treatise  of  Mr.  Ramsbotham,  just  mentioned:  and  I  may  here 
take  occasion  to  say,  it  is  not  only  for  this  subject,  but  several 
others  of  high  interest,  I  would  recommend  every  practitioner  of 
midwifery  to  the  perusal  of  his  vv^ork. 

d.  IV. —  Where  everything  is  as  at  III.  excejjt  that  the  Uterus 
enjoys  its  full  power. 

1174.  This  variety  is  not  only  less  frequent,  but  is  much  less 
dangerous,  than  the  one  just  spoken  of;  for  the  uterus,  when  en- 
joying its  full  powers,  will  contract,  with  sufficient  force  to  pre- 
vent any  serious  mischief  from  haemorrhage,  though  there  may 
be  considerable  waste  before  the  uterus  is  emptied  of  the  placenta 
— this  requires  the  same  manual  treatment  in  the  beginning,  and 
the  same  medical  routine  for  the  subsequent  symptoms.! 

*  A  considerable  variety  of  substances  have  been  proposed  for  this  purpose: 
as  alum  and  water,  wine  and  water,  wine  alone,  vinegar,  &c. — but  what  has  an- 
swered best  in  my  hands,  in  the  very  few  instances  of  this  kind  which  have  fallen 
under  my  notice,  has  been  a  strong  infusion  of  chamomile  flowers,  in  which 
a  piece  of  quicklime  has  been  slacked,  and  permitted  to  settle  perfectly  cleai-. 
This  may  be  used,  moderately  warm,  three  or  four  times  a  day,  or  oftener  if  re- 
quired. The  common  pewter  syringe  for  enemata,  with  a  flexible  tube  attached 
to  it,  answers  perfectly  well — the  gum  elastic  tubes,  for  the  tliroat  or  bladder, 
may  be  very  reacUly  fixed  to  the  extremity  of  tliis  instrument.  In  one  instance, 
I  saw  port  wine  and  water,  with  a  little  alum,  used  with  great  advantage. 

f  Tlicre  is  a  variety  in  this  division,  which  cannot  be  considered  as  strictly 
l)elonging  to  the  subject  under  consideration;  yet  its  own  importance  will,  I 
hope,  be  a  suflicient  apology  for  introducing  it  here — it  is,  where  the  placenta  is 
completely  adherent,  and  tlic  uterus  powerfully  contracts  upon  this  mass,  and 
prevents  the  introduction  of  ihe  hand,  or  of  even  a  couple  offingers,  for  the  re 


THE  PLACENTA  IS  EXPELLED.  -127 

e.  V.  —  Where  there  is  an  entire,  or  partial  separation,  but  the 
Uterus  in  a  state  of  exhaustion  or  syncope. 

1175.  This  variety  is  most  truly  alarming,  and  requires  the 
most  prompt  and  judicious  interference,  that  the  woman  may  not 
almost  instantly  die.  The  case  occurs:  1st.  Where  a  long-pro- 
tracted labour  has  much  exhausted  the  patient,  previously  to  de- 
livery, but  where  delivery  has  eventually  been  unexpectedly 
sudden.  The  uterus,  from  previous  fatigue  and  exertion,  becomes 
enfeebled,  though  capable  for  the  moment  of  a  powerful  effort, 
which  suddenly  terminates  the  labour,  but  by  which  its  power  is 
expended — the  placenta,  from  the  long-continued  and  frequently 
repeated  pains,  was  ready  to  separate,  and  waited  but  for  the  con- 
traction which  expelled  the  child,  to  destroy  its  connection  with 
the  uterus,  to  fall  loose  or  nearly  so  into  its  cavity,  and  thus 
give  opportunity  to  the  exposed  vessels  to  pour  out  a  torrent  of 
blood.  2d.  It  takes  place,  and  this  more  frequently  than  from  the 
cause  just  mentioned,  when  the  labour  has  been  very  rapid;  and 
where  the  child  seemed  to  be  floated  from  the  uterus  by  a  sudden 
gush  of  the  waters — under  such  circumstances,  the  uterus  is  some- 
times instantly  deprived  of  its  tonic  power,  and  thrown  into  a 
state  of  absolute  syncope,  as  it  has  been  happily  termed  by  Leroux. 
Or,  3dly.  It  may  arise,  (and  it  but  too  often  does,)  from  the  too 
hasty  delivery  of  the  child,  after  the  head  has  esoaped  through 
the  OS  externum — here  I  would  wish  to  caution  the  young  prac- 
titioner against  one  of  the  most  formidable  errors  that  can  be  com- 
mitted against  sound  practice,  or  just  principles.  For  at  this 
moment,  the  uterus  has  expended  much  of  its  power,  in  pushing 
the  child  thus  far;  and  if  some  little  time  be  not  allowed  it  to  re- 
cover its  nearly  expended  strength  before  the  body  is  hurried 
through  the  pelvis,  it  will  be  sure  to  increase,  and  perpetuate  the 
inertia,  into  which  it  has  just  fallen  from  severe  exertion:  hence, 

moval  of  it,  were  this  even  practicable.  It  is  fortunately,  of  I'are  occurrence — 
I  have  seen  but  two  cases  of  it;  in  neither  of  which  was  there  flooding;  indeed, 
scarcely  a  drop  of  blood  was  discharged  in  tlie  one  instance,  and  in  the  other 
only  a  few  small  coagada  were  expelled,  the  whole  not  amounting  to  four 
ounces.  Tins  case  must  be  trusted  to  nature;  for  after  repeated  examinations 
the  uterus  was  not  found  to  relax  sufficiently,  even  to  attempt  the  removal  of 
the  placenta.  This  mass  was  expelled  entire,  on  the  third  day,  in  the  one  case, 
without  any  unpleasant  consequences;  but  in  the  other,  it  employed  many 
days  before  it  was  thrown  from  the  uterus,  and  then  in  small  detached  masseg 
accompanied  with  great  foctor,  thirst,  and  fever.  The  patient  eventually  did. 
well,  though  she  remained  weak  a  considerable  time. 


428  HEMORRHAGE,  BEFORE 

we  have  always  to  apprehend  a  flooding,  where  the  shoulders  are 
expelled  by  the  same  effort  that  delivers  the  head;  more  especi- 
ally, if  the  child  be  large,  and  the  waters  but  very  recently  ex- 
pended; or  where  the  child  is  small,  and  the  quantity  of  w^ater 
great,  and  that  but  a  short  time  discharged.  Should  this  condi- 
tion be  accompanied  with  a  partial  separation  of  the  placenta, 
an  alarming  haemorrhage  will  necessarily  ensue;  and  if  with  an 
entire  one,  death  may  be  the  almost  immediate  consequence. 

1176.  When  haemorrhage  proceeds  from  either  of  the  causes 
just  stated,  it  will  be  evident  that  nothing  but  the  most  prompt 
interference,  and  the  employment  of  the  most  active  agents,  can 
prevail  against  so  formidable  an  issue  of  blood,  as  now  pours  from 
the  vagina.  No  time  must  be  lost  by  temporizing;  the  woman 
will  sink  if  not  instantly  succoured.  Frictions  upon  the  abdomen 
should  be  quickly  commenced,  and  be  actively  pursued;  doses 
of  ergot — cold  water  poured  from  a  height  upon  the  abdomen,  if 
the  frictions  do  not  very  soon  recall  the  contractile  power  of  the 
uterus;  and  if  much  faintness  from  the  loss  of  blood  attend,  a 
small  quantity  of  moderately  strong  brandy  and  water  should  be 
given  every  few  minutes,  until  this  disposition  is  relieved ;  this 
will  pretty  soon  follow  its  exhibition,  if  the  means  for  re-exciting 
the  uterus  should  be  successful.  Fresh  air  should  be  freely  ad- 
mitted, but  the  feet  and  legs  should  be  kept  warm  by  bottles  of 
warm  water  or  heated  flannels;  the  ergot  should  be  instantly 
given  in  small  but  frequently  repeated  doses;  that  is,  five  grains 
every  ten  minutes,  for  two  or  three  doses.  But  should  this  not 
excite  contraction  promptly,  twenty  grains  should  next  be  given, 
and  repeated  again  and  again  if  necessary.  It  is  presumed  that 
during  this  time  frictions  upon  the  abdomen  and  other  means 
would  be  employed. 

1177.  Since  the  last  edition  of  this  work,  I  have  had  several 
instances  of  flooding  in  which  I  have  had  recourse  to  the  ergot 
with  entire  success ;  I  can  therefore  now,  and  do  with  much 
pleasure,  add  my  testimony  to  that  of  others  in  its  favour. 

1178.  But  I  must  here  repeat,  that  my  great  dependence  is 
upon  the  abdominal  frictions ;  having  so  far  never  known  them 
to  fail.  Some  practitioners  have  introduced  ice*  into  the  cavity 
of  the  uterus,  under  these  circumstances,  and  it  is  said  with  suc- 
cess.    I  can  say  nothing  upon  the  influence  of  this  remedy  from 

*  Levret,  I  believe,  was  tlie  first  who  had  recourse  to  this  remedy  in  the  man- 
ner above  stated,  and  it  lias  since  been  recommended  by  otliers — it  has  lately 
been  advised  by  Mr.  Barlow. 


THE  PLACENTA  IS  EXPELLED.  429 

my  own  experience,  and  were  I  tempted  to  employ  this  substance, 
1  should  not  judge  it  necessary  to  conduct  it  within  the  cavity  of 
the  uterus ;  from  a  belief,  (not,  however,  I  confess,  confirmed  by 
trial,)  that  it  would  be  everyway  as  effectual,  if  it  were  held  in 
the  vagina.  I  shall  illustrate  this  condition  by  a  case  taken  at 
random  from  a  number  of  similar  ones — for  all  these  cases  are  so 
much  alike,  as  to  require  but  one  general  mode  of  treatment. 

Mrs. was  delivered  by  a  midwife,  after  a  very  easy  but 

rapid  labour,  of  a  healthy  fine  child — the  placenta  was  very 
quickly  expelled,  as  it  was  found,  as  the  midwife  said,  loose  in 
the  vagina;  a  very  profuse  flooding  immediately  ensued,  for  the 
relief  of  which  she  attempted  nothing,  assuring  the  friends  of  the 
lady  it  was  a  common  occurrence,  and  from  which  nothing  was 
to  be  apprehended — but  the  patient  becoming  pale  and  faint,  her 
friends  were  alarmed,  and  I  was  sent  for  in  great  haste.  After 
my  arrival,  I  was  informed  that  the  patient  had  been  delivered 
about  twenty  minutes,  and  the  placenta  had  been  extracted  about 
fifteen  of  that  time.  When  I  came  to  the  bed-side,  I  was  per- 
suaded the  patient  was  dead — no  pulse  could  be  felt,  and  for  some 
time  there  was  no  respiration  ;  syncope  had  just  taken  place.  I 
instantly  commenced  a  brisk  friction  upon  the  abdomen — order- 
ed brandy  and  water  by  the  tea-spoonful  to  be  given  with  fre- 
quency ;  warm  applications  to  be  made  to  the  feet  and  legs — the 
curtains  to  be  opened, and  fresh  air  admitted  from  the  door  and  win- 
dows, and  immediately  sent  for  pills  of  the  acetate  of  lead  and 
opium.  In  the  course,  perhaps,  of  two  minutes  after  the  abdo- 
minal frictions  were  commenced,  I  had  the  satisfaction  to  feel  the 
uterus  beginning  to  harden  under  the  hand,  and  every  instant 
after,  to  acquire  more  and  more  firmness;  in  about  ten  minutes  it 
was  found  much  diminished  in  size,  and  much  more  solid — in  the 
act  of  puckering  itself  up,  a  large  quantity  of  coagula  and  fluid 
blood  were  expelled  from  the  vagina,  which  so  alarmed  the  igno- 
rant midwife,  to  whom  was  consigned  the  task  of  watching  the 
discharge,  that  she  declared  the  woman  must  die  if  I  did  not  de- 
sist from  '<  rubbing  the  womb  so  violently;"  but  the  cause  of  this 
poor  creature's  alarm  was  to  me  a  great  comfort,  and  only  induc- 
ed me  the  more  steadily  to  persevere  in  the  plan  of  irritating  the 
uterus. 

The  disposition  to  syncope  was  now  much  lessened,  and  the 
pulse  could,  by  a  nice  examination,  be  felt  returning  to  the  wrist 
— increasing  in  volume  and  force  as  the  faintness  diminished;  and 
in  about  half  an  hour  more  the  patient  was  considered  out  of  im- 


430  ITiEMORRnACE,  BErOHE 

mediate  risk.  To  guard  against  a  return  of  the  flooding  as  effec- 
tually as  might  be,  I  directed  two  grains  of  the  acetate  of  lead, 
and  a  half  grain  of  opium,  to  be  given  every  half  hour;  the  fric- 
tions upon  the  abdomen  to  be  renewed,  should  the  uterus  be  found 
to  relax  ever  so  little;  and  for  this  end,  a  very  intelligent  lady 
present,  was  instructed  to  perceive  any  change  of  this  kind  that 
might  take  place — the  brandy  and  water  to  be  given  only  pro  re 
nata;  and  the  most  perfect  rest  was  enjoined,  though  the  position 
of  the  patient's  body  was  a  very  constrained  one.  I  again  saw 
my  patient  in  about  two  hours,  (having  given  orders  to  be  in- 
stantly sent  for,  in  case  of  any  unfa%'Ourable  change  before  I  re- 
turned,) and  found  her  situation  in  every  respect  improved;  she 
had  had  no  return  of  haemorrhage,  but  was  occasionally  troubled 
with  after-pains— her  faintness  had  gone  off  entirely,  and  her 
system  was  re-acting  with  considerable  force — her  position  was 
now  altered  very  much  to  her  satisfaction;  the  brandy  and  water 
was  stopped,  and  she  was  permitted,  instead  of  it,  to  take  a  few 
spoonsful  of  tapioca,  seasoned  with  lemon  juice  and  sugar,  from 
time  to  time — the  pills  of  the  acetate  of  lead  were  directed  once 
in  two  hours.  From  this  time  her  recovery  was  as  rapid  as  such 
a  prodigious  waste  of  blood  would  permit;  milk  was  formed  in 
sufficient  quantity  after  rather  a  longer  period  than  usual,  and 
the  only  subsequent  inconvenience  she  experienced  was  a  head- 
ache; which  almost  invariably  follows  excessive  uterine  haemor- 
rhage; this  was  relieved  by  keeping  the  bowels  freely  open. 

f.  VI. —  Where  there  is  either  a  jiartial  or  co7nj)lete  sejjaration 
of  the  Placenta,  and  where  the  body  and  fundus  are  in  a 
state  of  inertia,  while  the  neck  enjoys  its  tonic  powers. 

1179.  This  is  the  most  insidious  situation  in  which  the  uterus 
can  well  be  placed;  and  it  is  one  in  which  inexperienced  practi- 
tioners lose  patients  more  frequently  than  any  other,  after  the 
birth  of  the  child.  The  neck  of  the  uterus  enjoying  its  powers, 
at  a  time  that  both  fundus  and  body  are  in  a  state  of  inertia,  gives 
rise  to  such  an  accumulation  of  blood  within  the  uterine  cavity, 
as  will  destroy  the  patient,  without  its  being  suspected  that  such 
a  discharge  is  going  on — in  this  case,  the  haemorrhage  will  be 
concealed;  for  a  coagulum  blocking  up  the  os  uteri,  will  prevent 
either  fluid  blood,  or  coagula,  from  issuing;  and  as  there  is  no 
apparent  flooding,  the  inexperienced  accoucheur  rests  satisfied 
(hat  all  is  going  on  well:  nor  is  he  roused  always  from  this  state 


THE  PLACENTA  IS  EXPELLED.  431 

of  security,  until  the  patient  is  in  articuio  mortis;  or  when,  per- 
haps, all  human  aid  would  be  unavailing. 

1180.  This  case  should  warn  the  practitioner  of  limited  expe- 
rience, against  a  false  estimate  of  liis  patient's  security;  and 
should  teach  him  never  to  failj  ascertaining  the  state  of  the  ute- 
rus, by  a  careful  examination,  through  the  abdominal  parietes,  as 
already  advised.  If,  upon  placing  his  hand  upon  the  abdomen, 
he  find  the  uterus  voluminous,  but  far  from  being  hard;  if,  upon 
inquiry,  he  learn,  that  there  is  little  or  no  discharge  from  the 
vagina;  if  he  observe  his  patient  become  pale  and  faint,  with  a 
hurried  breathing;  if,  upon  touching  the  wrist,  he  find  the  pulse 
weak,  frequent,  or  extinct;  the  skin  cold  and  clammy,  lie  may 
be  pretty  certain  there  is  a  concealed  haemorrhage;*  he  has  now 
not  a  moment  to  lose,  to  rescue  the  woman  from  an  impending 
fate — he  must  be  firm,  prompt,  and  self-collected;  and  instantly 
put  in  practice  every  remedy  that  may  promise  relief. 

1181.  He  should  commence  by  abdominal  frictions;  and,  if  he 
find  the  uterus  becoming  harder  in  consequence,  he  should  per- 
severe, until  he  thinks  it  has  acquired  a  disposition  to  contract 
— should  the  hardening  of  the  uterus  not  be  attended  with  a  dis- 
charge of  coagula,  &c.  from  the  vagina,  he  must  conclude,  either 
that  the  neck  of  the  uterus  is  too  resisting  to  be  overcome  by  the 
contraction  of  the  body  and  fundus,  without  farther  aid,  or  that 
these  are  too  feeble  to  overcome  the  resistance  of  the  os  uteri, 
though  the  latter  may  be  comparatively  weak — in  either  case,  he 
must  attempt  to  give  to  the  uterus  an  increase  of  power,  by  re- 
moving its  contents. 

1182.  This  must  be  conducted  with  much  cautious  coolness, 
that  the  remedy  must  not  increase  the  evil — the  frictions  upon 
the  abdomen  must  be  intrusted  to  some  proper  assistant,  and  they 
should  be  kept  up  with  persevering  constancy,  while  the  practi- 
tioner carefully  inserts  his  hand  into  the  vagina — should  he  find 
clots  there,  he  should  remove  them,  if  they  ai'e  not  immediately 
forced  oft'  by  the  effort  which  will  most  probably  be  excited,  by 
the  introduction  of  the  hand. 

1183.  This  being  done,  he  is  to  insinuate  finger  after  finger  into 
the  OS  uteri,  and  gradually  attempt  its  dilation;  should  it  be  very 
resi'iting,  the  resistance  must  be  cautiously  overcome;  and  if  this 

*  I  say,  '*  pretty  certain  thei-e  is  a  concealed  hxmorrliag'e;"  foi- 1  cannot  say 
he  may  be  altogether  certain;  since  a  rupture  of  the  uterus  may  be  attended 
w  iUi  all  these  symptoms. 


432  HEMORRHAGE,  &C. 

be  properly  conducted,  it  will  perhaps,  never  offer  such  opposi- 
tion, as  to  render  any  considerable  force  necessary — perseve- 
rance in  a  well-directed  manner;  I  am  persuaded,  will  be  all  that 
is  necessary. 

1184.  When  the  hand  has  gained  possession  of  the  cavity  of 
the  uterus,  the  wrist  should  be  so  pressed  against  the  side  of  the 
neck  of  the  uterus,  as  to  make  room  for  the  escape  of  any  coagula 
or  fluid  blood,  that  may  be  disposed  to  issue — by  managing  in  this 
way,  he  may  empty  the  uterus  so  gradually,  as  almost  to  insure 
its  subsequent  contraction,  and  this  will  be  much  aided  by  the  ex- 
ternal friction.  He  is  now  to  search  for  the  placenta;*  if  it  be 
but  partially  detached,  he  must  cautiously  separate  the  remaining 
adhesions — when  this  is  done  with  care,  and  under  the  precau- 
tions above  suggested,  he  is  to  remove  it  by  rotating  the  hand  now 
in  possession  of  the  placenta,  against  the  internal  surface  of  the 
uterus,  until  it  manifest  a  disposition  to  contract;  and  then,  and 
not  till  then,  should  the  hand  be  withdrawn. 

1185.  Should  the  placenta  be  found  entirely  detached,  it  must 
be  delivered  with  the  same  regard  to  uterine  contraction.  After 
the  delivery  of  the  placenta,  pressure  and  friction  should  be  con- 
tinued upon  the  abdomen;  nor  must  these  be  abandoned,  until 
the  contracted  uterus  give  assurance  of  recovered  energy. 

1186.  In  addition  to  what  has  now  been  directed,  the  other  re 
medies  which  have  been  suggested  should  be  had  recourse  to — 
the  sugar  of  lead,  ergot,  and  cold  applications,  under  the  restric- 
tions already  proposed,  should  be  tried — this  case,  and  the  one 
next  to  be  considered,  offer,  perhaps,  the  best  chances  for  the  er- 
got; the  brandy  and  water  should  not  be  omitted,  if  the  woman  be 
very  faint,  and  much  exhausted.  The  after-treatment  will  sug- 
gest itself;  and  after-symptoms  must  be  treated  pro  re  nata. 

*  It  may  be  well  to  observe  that,  in  every  attempt  to  separate  the  placenta, 
we  sliould,  before  we  commence  tlie  operation,  fix  the  uterus  as  firmly  as  it  can 
wellbe  done,  by  tl\e  external  application  of  the  unemployed  hand  upon  the  fun- 
Jus — in  fact,  it  should  never  be  attempted  without  this  precaution;  as  the  ope- 
ration is  not  only  very  difficult,  if  this  be  neglected,  but  is  also  very  uncertain — 
the  woman  if  possible,  should  be  placed  upon  her  back,  as  I  have  directed  for 
other  purposes.  It  may  also  be  proper  to  suggest  another  caution  connected 
with  this  operation,  which  is,  that  we  be  certain  that  we  have  removed  the 
whole  of  the  placenta;  except  in  those  cases,  where  it  is  expedient  to  leave  a 
portion  to  the  natural  efforts  of  the  uterus,  as  in  the  too  adherent  placenta.  It 
is,  however,  sometimes  almost  impossible  to  determine  this,  where  the  placenta 
islobulated,  as  now  and  then  happens.     See  Leroux,  Buudelocque,  8ic. 


HiEMORRUAGE,  &.C.  433 

Sect.  VIIL — 8.    Of  Flooding  after  the  expuhioa  of  the 
Placenta. 

11S7.  When  the  placenta  has  been  expelled,  and  is  followed 
by  flooding,  the  mode  of  proceeding  is  so  similar  to  the  last  re- 
commended, that  it  will  require  but  a  few  words  to  make  its  ma- 
nagement perfectly  clear.  In  this  kind  of  hsemorrhage,  like  the 
one  we  have  just  been  considering,  it  is  necessary  that  the  uterus 
should  contract  before  it  can  possibly  be  arrested ;  therefore  it 
will  require  the  employment  of  all  the  means  already  pointed  out 
for  this  purpose ;  and  here,  as  in  the  other  cases,  I  rest  my  great 
dependence  upon  abdominal  frictions,  the  acetate  of  lead,  ergot, 
cold  applications,  &c. 

1188.  Should  the  concealed  haemorrhage  take  place,  it  must  be 
treated  much  after  the  same  manner  as  before  the  placenta  is 
expelled;*  (1179,  &c.)  that  is,  the  hand  must  be  introduced  into 
the  uterus,  and  the  coagula  suffered  gradually  to  escape,  while 
the  uterus  is  gently  stimulated  by  the  hand  passing  cautiously 
over  its  surface ;  and  when  it  is  found  to  contract  upon  it,  it  may 
be  slowly  withdrawn ;  the  after-treatment  must  necessarily  be 
the  same.  This  case,  generally  speaking,  is  of  much  less  diificuU 
treatment  than  where  we  have  the  placenta  to  contend  with ; 
and  will  always,  so  far  as  I  have  yet  experienced,  yield  to  the 
treatment  proposed,  provided  a  proper  chance  be  given  to  their 
employment — it  cannot  be  supposed  they  will  be  availing  when 
the  patient  is  in  articulo  mortis. 

1189.  It  sometimes,  however,  happens,  that  a  portion  of  the 
placenta  is  left,  either  entirely,  or  partially  attached  to  the  ute- 
rus, which  will  give  rise  sooner  or  later  to  haemorrhage — this  may 
sometimes  be  immediately  detected  by  the  inspection  of  the  pla- 
centa itself — at  other  times  this  will  be  found  impossible;  espe- 
cially in  those  cases  where  we  are  under  the  necessity  of  bring- 

*  This  case  is  sometimes  very  suddenly  fatal.  I  was  once  called  by  a  mid- 
wife, to  visit  one  of  her  patients;  but  upon  my  arrival,  I  found  the  woman 
dead.  The  midwife  was  much  surprised,  and  could  not  account  for  her  death; 
as  "  the  labour  was  natural  and  easy,  and  the  placenta  had  come  quickly  away." 
I  told  her  my  suspicions  of  the  case;  and  these  were  afterwards  confirmed,  by 
opening'  the  body — the  whole  cavity  of  the  uterus  was  filled  with  blood,  and 
distended  to  nearly  the  size  of  one  at  the  full  period  of  gestation— the  mouth  of 
the  uterus  was  found  sufficiently  closed  to  retain  the  blood  dischai-ged  from 
the  sui-face  to  which  the  placenta  lad  been  attached. 
55 


434  HEMORRHAGE,  &C. 

ing  away  this  mass  piecemeal — if  this  accident  he  discovered  at 
once,  it  is  best,  I  believe,  to  remove  it;  unless  it  should  be  a  por- 
tion that  is  too  adherent.  Should  this  not,  however,  be  discover- 
ed before  the  uterus  has  contracted  firmly  upon  it,  it  will  be  much 
better  to  suffer  it  to  remain,  and  trust  to  nature  for  its  expulsion, 
than  to  run  the  risk  of  provoking  a  flooding;  exciting  a  great  deal 
of  pain,  or  of  producing  inflammation.  But  should  flooding  at- 
tend, we  must  deliver  the  retained  portion,  and  this  can  almost 
always  be  done,  as  the  mouth  of  the  uterus  is  generally  found 
open  or  yielding  when  haemorrhage  attends;  but  should  it  be 
found  otherwise,  it  must  be  trusted  to  nature;  the  excess  of  dis- 
charge must  be  moderated  by  the  tampon — if  this  be  employed, 
it  will  be  well  to  renew  it  every  twelve  hours;  taking  care  to 
wash  out  the  vagina  before  it  is  replaced,  with  the  infusion  of 
chamomile  tea,  wine  and  water,  &c. 

1190.  The  retained  portion  of  the  placenta  sometimes  may  not, 
however,  be  suspected  for  several  days  after  deliver}^;  but  we 
have  a  right  to  conclude  that  it  is  retained,  when  there  is  frequent 
return  of  pains,  and  a  discharge  of  coagulum  after  coagulum  from 
the  vagina,  followed  by  fluid  blood  upon  each  relaxation  of  the 
uterus.  When  the  discharge  of  fluid  blood  happens  in  quick  suc- 
cession and  in  weakening  quantities,  we  should  immediately  at- 
tend to  the  condition  of  the  uterus;  if  it  be  found  sufiiciently 
yielding  to  admit  the  hand,  it  must  be  carefully  introduced,  and 
the  portion  detached,  and  withdrawn. ''  We  may  sometimes  suc- 
ceed in  detaching  it  by  insinuating  a  couple  of  fingers  into  the 
uterus,  and  moving  them  in  a  circular  manner  between  it  and  the 
placenta,  so  as  to  loosen  it,  and  then  remove  it  either  by  hooking 
it  with  the  finger;  by  the  natural  efibrts  of  the  uterus;  or  by  the 
small  crotchet  recommended  for  the  removal  of  the  secundines  in 
cases  of  early  abortion.  If  neither  the  finger  nor  the  crotchet 
succeed,  we  must  trust  to  nature;  taking  care  to  keep  the  dis- 
charge in  subjection  by  the  tampon. 

1191.  The  young  practitioner  is  cautioned  against  treating  this 


♦  Baudelocque  tells  us,  he  has  known  this  kind  of  haemorrhage  show  itself 
on  the  tenth  day,  and  has  been  obliged  to  pass  the  hand  into  the  uterus,  to  ex- 
tract it.  (System,  Vol.  II.  p.  27.)  I  am,  however,  disposed  to  think,  that  in 
cases  of  this  kind,  the  ergot  would  be  the  better  remedy;  it  should  be  tried  at 
least.  It  is  true,  that  this  opinion  is  founded  upon  its  success  in  a  single  case. 
But  analogy  is  so  mucli  in  its  favour  independently  of  this,  we  must  repeat  it, 
it  should  be  triedj  it  may  save  botli  time  and  pain. 


MEANS  FOR  PREVENTINft  HiEMORRHAGE.  435 

case  with  indifference;  it  is  one  not  unfrequently  attended  with 
danger,  and  sometimes  death  has  ensued  very  quickly,  as  La 
Blotte  and  others  assure  us.  Should  he  be  doubtful  of  his  own 
judgment  in  this  case,  let  him,  b}'-  all  means,  (as  well  as  in  every 
other  case  of  danger,)  request  the  advice  of  an  older  practitioner. 

Sect.  IX. — 9.  On  the  means  for  jircvcnting  Flooding. 

1192.  Having  considered  at  some  length  the  haemorrhages 
which  may  take  place  during  pregnancy,  and  such  as  may  follow 
delivery,  let  me  say  a  few  words  upon  the  mode  of  preventing 
those  which  may  succeed  to  labour,  as  I  am  of  opinion  that  much 
may  be  done  to  this  purpose.  From  what  has  been  said,  it  will 
be  evident,  that  whatever  interrupts  the  tonic  contraction  of  the 
uterus,  or  produces  its  relaxation  after  it  has  contracted,  will 
occasion  a  flooding;  provided  there  be  a  separation  of  a  part,  or 
of  the  whole  of  the  placenta;  it  is  equally  evident,  that  whatever 
will  insure  this  contraction,  or  contribute  to  it,  will  either  pre- 
vent or  diminish  haemorrhage  from  this  part.  Much,  then,  will 
depend  upon  the  manner  in  which  the  last  stage  of  labour  is  con- 
ducted, to  insure  the  future  contraction  of  the  uterus. 

1193.  This  subject  has  been  treated  by  Dr.  Denman,  with 
much  apparent  interest;  but  his  advice  upon  this  point  is  not  con- 
formable to  my  own  experience.  I  shall  quote  his  directions  in 
his  own  words.  The  doctor  says,  "  when  I  had  been  attending 
women  who  were  prone  to  violent  haemorrhages  after  the  birth 
of  the  child  in  former  labours,  I  have  made  it  a  rule  to  keep  them 
in  an  erect  position  till  the  waters  were  discharged  by  the  spon- 
taneous breaking  of  the  membranes,  and  the  child  was  on  the 
point  of  being  born.  By  this  method  it  appeared  clearly  to  me, 
that  the  uterus  acted  more  favourably,  the  placenta  came  away 
more  naturally,  and  the  quantity  of  blood  lost  was  often  much 
more  diminished."* 

1194.  Now,  I  ask  any  one  at  all  conversant  with  the  economy 
of  the  uterus,  during,  and  after  labour,  how  an  erect  position,  the 
sudden  evacuation  of  the  waters  at  the  moment  "  the  child  was 
about  to  be  born,"  can  contribute  to  the  only  circumstance  at  all 
available  in  the  case  under  consideration,  namely;  the  perma- 
nent contraction  of  the  uterus?  In  the  first  place,  an  erect  posi- 
tion will  always  be  attended  with  a  quicker  circulation  than  a 

'  Introduction  to  Midwifery,  Francis's  ed.  p.  494. 


436  MEANS  FOK  PREVENTING  II^MORRHACxE. 

recumbent  one;  and  will  permit  the  waters  to  escape  with  more 
suddenness  and  rapidity;  consequently,  the  risk  of  atony  must  be 
increased.  It  is  admitted  upon  all  hands,  and  among  these,  by 
Dr.  D.  himself,  in  other  parts  of  his  works,  that  if  the  uterus  be 
too  suddenly  emptied,  there  will  be  a  risk  of  inertia,  or,  at  least, 
of  great  irregularity  of  action;  if  this  be  so,  how  can  the  interest 
of  the  woman  be  improved  by  this  practice? 

1195.  All  writers  upon  midwifery  declare,  that  the  sudden 
evacuation  of  the  waters,  and  the  delivery  of  the  child  almost  at 
the  same  instant,  are  the  most  common  causes  of  the  atonic  state 
of  this  organ.  Yet  we  are  advised  by  Dr.  D.  to  encourage  these 
events,  with  a  view  to  prevent  it!  So  far  all  theory  is  against  it; 
and  I  will  now  appeal  to  experience  to  prove  it  to  be,  at  least  a 
doubtful  practice. 

1196.  There  was  a  period  of  my  life  at  which  I  looked  upon 
Dr.  Denman  to  be  the  highest  authority  in  midwifery;  and,  at 
that  time  almost  implicitly  followed  his  instructions  upon  every 
point  of  practice;  and  consequently  upon  the  subject  in  question. 
But  in  doing  so,  I  was  persuaded  from  sufficient  trials  of  the  plan, 
that  it  not  only  did  not  answer  the  end  for  which  it  was  pro- 
posed, but  that  it  was  decidedly  mischievous;  I  of  course  aban- 
doned it  so  soon  as  I  was  convinced  of  this  truth;  and  substituted 
one  almost  diametrically  opposite;  and  with  which  I  have  every 
reason  to  be  satisfied.  As  it  was  impossible  to  determine,  a.  priori, 
which  patient  might  be  attacked  with  a  flooding  after  deliv- 
ery, it  became  necessary  to  follow  some  general  rule  with  all, 
(where  practicable,)  by  which  the  risk  of  this  accident  should  be 
diminished. 

1197.  It  therefore  suggested  itself  that  whatever  would  insure, 
with  most  certainty,  the  tonic  contraction  of  the  uterus,  would 
best  guard  the  patient  against  the  contingency  of  a  flooding;  and 
what  appeared  to  me  the  most  rational  to  insure  this,  was  to  take 
off"  the  distention  of  this  viscus  as  gradually  as  possible,  by  the 
early  evacuation  of  the  waters;  to  diminish  the  force  of  the  circu- 
lation as  much  as  was  practicable,  by  making  the  woman  pre- 
serve a  horizontal  posture  when  the  pains  became  urgent;  and 
to  interdict  stimuli  of  every  kind,  as  wine,  or  any  other  liquor, 
heat,  and  all  unnecessary  exertion. 

1198.  But  let  me  make  myself  understood,  when  I  say  '^  the 
early  evacuation  of  the  waters."  It  is  a  fact  notorious  to  every 
practitioner,  that  the  membranes,  if  left  to  be  ruptured  entirely 


MEANS  FOR  PREVENTING  HEMORRHAGE.  437 

by  the  force  of  the  uterus,  would  remain  entire  in  many,  and,  per- 
haps, in  most  instances  until  the  child  was  about  to  be  pushed 
through  the  os  externum.  Now  were  this  plan  to  be  pursued, 
the  uterus  would  be  suddenly,  instead  of  gradually  emptied;  and 
consequently  the  risk  of  flooding  would  almost  necessarily  be  in- 
curred. But  if,  instead  of  this,  we  rupture  the  membranes  so  soon 
as  the  labour  is  active,  and  the  os  uteri  sufficiently  dilated,  or 
easily  dilatable,  we  should  give  opportunity  and  time  for  the 
uterus  to  contract,  before  the  child  would  be  expelled,  and  thus 
guard  against  the  evil  we  are  apprehending.  The  uterus  would, 
by  this  plan,  diminish  in  size  in  the  exact  proportion  to  the  water 
displaced;  it  would  apply  itself  to  the  whole  surfaceof  the  child, 
the  inequality  of  which  would  serve  as  an  important  and  healthy 
stimulus,  (all  things  being  equal,)  and  excite  it  to  more  certain 
contraction. 

1199.  Daily  experience  proves  the  justness  of  this  reasoning 
and  practice;  for  how  rarely  do  we  see  a  flooding  follow  those 
deliveries  where  the  liquor  amnii  has  been  discharged  even  a  few 
hours  previously !  and  what  can  produce  the  exemption  from  this 
accident,  but  the  uterus  having  had  sufficient  time  and  opportu- 
nity to  contract?  It  is  true,  that  this  alone  may  not  always  be 
sufficient  to  protect  the  woman  against  a  haemorrhage,  but  I  am 
convinced,  from  many  years  of  experience,  it  is  the  principal' 
one.*     The  directions  given  for  the  delivery  of  the  body  of  the 

•  I  have,  within  the  last  few  years,  given  the  sccale  cornutiim  a  short  time  prc- 
v'iously  to  the  delivery  of  the  child,  with  tlie  happiest  effect.  It  was  given,  as 
declared  in  the  following  case: — 

Mi-s. ,  aged  thirty -three  years,  in  labour  with  her  seventh  child.     One 

of  her  friends  informed  me,  that  she  had  always  been  liable  to  flood  exces- 
sively very  soon  after  the  expulsion  of  the  placenta;  and  that  with  the  child 
before  the  present  one,  she  had  been  nearly  exhausted  by  the  profuseness  of 
the  discharge.  To  prevent  a  recurrence  of  this,  I  prescribed  the  following  mix- 
ture:— 

R     Pulv.  Secale  Cornut.        ^ss. 
Sacch.  Alb.  giss. 

Aq.  Cinnam.  simp.  §j. M. 

Of  this,  one-tliird  was  given  every  twenty  minutes,  about  an  hour  before  the 
child  was  expected  to  be  born.  The  child  was  delivered  in  three  quarters  of 
an  hour  after  the  first  dose.  The  placenta  was  soon  detached,  b}^  the  efforts 
of  the  uterus  alone;  and  was  found  to  be  firmly  contracted,  immediately  after. 
No  flooding  supervened — indeed,  nothing  but  a  moderate  lochia  followed. 

Mrs. ,  aged  twenty-six,  of  rather  a  leucophlegmatic  habit,  and  excessive- 
ly afflicted  with  fluor  iilbus,  had  with  her  first  child  a  painful,  but  active  labour 
of  about  three  hours  continuance.   Very  soon  after  the  delivery  of  the  placenta, 


438  MEANS  FOR  TREVENTING  HJEMORRHAGE. 

child,  after  the  head  has  escaped,  and  the  abdominal  frictions, 
must  also  be  considered  as  matters  of  great  moment,  and  should 
never  be  neglected,  especially  with  women  who  are  "  prone  to 
flood"  after  delivery. 

excessively  severe  after-pains  began,  accompanied  by  a  pretty  profuse  discharge 
of  blood  and  coagida.  These  were  repeated  in  very  quick  succession,  until  she 
became  very  faint,  and  much  exhausted.  I  gave  her  five  grains  of  the  acetate 
of  lead,  and  sixty  drops  of  laudanum;  frictions  were  made  upon  the  abdomen. 
In  half  an  hour  the  sugar  of  lead  was  repeated,  with  much  advantage;  the  pains 
and  dischai'ge  were  now  much  abated^  and  the  uterus  remained  pretty  per- 
manently contracted.  I  however  ordered,  in  case  pain  continued,  to  repeat  the 
laudanum,  witliout  the  sugai-  of  lead.  She  remained  very  weak  for  a  number 
of  days,  as  she  had  lost  a  great  deal  of  blood. 

Her  second,  tliird,  and  fourth  labours,  were  followed  by  the  same  disagreea. 
ble  consequences^  for  in  each  of  which  the  uterus  relaxed  itself,  after  the  expul- 
sion of  the  placenta,  after  having  been  firmly  contracted  for  half  an  hour.  AVitli 
her  fifth  laboui-.  May  24th,  1827,  I  resolved  upon  putting  in  practice,  the  early 
ruptm-ing  of  the  membranes,  and  the  exhibition  of  the  ergot.  After  her  pains 
became  active,  I  ruptui'ed  the  membranes,  tliough  the  uterus  was  not  fully  di- 
lated. In  about  an  hour  the  os  uteri  was  entu-ely  expanded,  and  the  labour 
advanced  with  considerable  rapidity;  about  twenty  minutes  before  I  expected 
delivery  would  take  place,  I  gave  her  five  grains  of  the  secale  cornutum,  and 
repeated  it  in  ten  miiHites,  and  in  ten  minutes  after  I  gave  ten  grains  more, 
making  twenty  grains  altogether.  Delivery  now  ensued;  the  placenta  was 
spontaneously  thrown  off"  in  twenty  minutes,  unattended  by  flooding,  and  fol- 
lowed by  very  little  pain.  I  waited  an  hour  and  a  half  but  no  hemorrhage  took 
place.  Thirty  drops  of  the  black  drop  had  been  given  immediately  after  tlie 
first  after-pain,  and  this  was  followed  by  twenty  more.  The  after-pains  ceased, 
and  the  lochial  discharge  was  very  moderate;  in  a  word,  she  was  better  on  the 
tliird  daj^  than  she  had  been  previously  at  the  end  of  a  fortnight. 

I  have  delivered  tliis  lady  four  times  since  May,  1827 — in  each  labour  the 
same  precautions  were  used,  with  similai-  hajjpy  results.  I  am  of  opinion,  that 
were  this  lady  neglected  after  delivery,  she  would  most  probably  die  from 
hsmorrhage;  for  with  even  attentions  sedulously  pursued,  a  strong  tendency  to 
relaxation  is  constantly  perceived  in  tJie  uterus,  for  the  first  hour  after  de- 
livery. 


(     439      ) 
CHAPTER  XXXII. 

OP  THE  ASSISTED  DELIVERY  OP  THE  PLACENTA, 

1200.  The  tonic  contraction  almost  exclusively  detaches  the 
placenta  from  the  uterine  surface,  in  order  that  it  may  be  expel- 
led. This  takes  place  at  various  periods  after  the  delivery  of  the 
child,  as  the  tonic  power  of  the  uterus  may  be  in  a  greater  or  less 
perfection,  or  as  the  connecting  medium  of  the  placenta  and  ute- 
rus may  be  more  or  less  dense — it  will,  therefore,  be  found,  that 
the  placenta  may  be  cast  off  immediately  after  the  expulsion  of 
the  child,  or  it  may  require  some  time  to  effect  this  end,  without 
our  considering  it  to  be  a  morbid  adhesion  of  this  mass.* 

1201.  It  is  desirable  at  all  times,  that  the  placenta  be  expelled 
pretty  quickly  after  the  child.  And  if  this  do  not  take  place 
spontaneously  in  due  time,  it  is  proper  that  we  should  give  such 
assistance  as  will  facilitate  its  exit,  without  the  introduction  of 
the  hand.  There  has  been  much  diversity  of  opinion,  what  pe- 
riod or  interval,  constituted  "the  proper  time,"  for  the  extrusion 
of  the  placenta — some  fixing  a  longer,  and  others  a  shorter  term, 
much  to  the  embarrassment  of  the  young  practitioner — but  this 
point,  I  conceive  is  easily  settled,  by  taking  the  indications  from 
the  condition  of  the  uterus  itself,  and  not  from  the  number  of  mi- 
nutes or  hours  which  may  have  elapsed. 

1202.  I  have  always  objected  to  making  "  time"  the  criterion 
for  action  in  midwifery;  and  my  aversion  is  by  no  means  abated, 
when  an  attempt  is  made  to  make  it  a  rule  for  the  delivery  of  the 
placenta;  for  the  same  objections  must  obtain  here,  as  in  the  cases 
I  have  already  declared  it  should  not  govern  in.  I  have  stated 
(1200)  by  what  power  the  separation  of  the  placenta  is  effected; 
and  that  it  would  necessarily  require  a  longer  or  shorter  interval, 
as  the  agent  may  be  more  or  less  active.  It  will  follow,  then, 
that  the  expulsion  of  this  mass  may  be  either  very  prompt,  (1200) 

•  We  may  remark  in  general,  that  the  time  the  uterus  requires  to  throw  off" 
the  placenta,  is  in  some  measure  indicated  by  the  state  of  the  foetal  circulation 
—if  this  be  quickly  interrupted  after  the  birth  of  the  child,  the  placenta  will  be 
detached  soon;  if  the  circulation  continue,  it  will  require  more  time.  This  may 
be  easily  understood;  as  cither  of  these'circumslanccs  betrays  tlic  want  of  great 
force  in  the  tonic  contraction. 


440  ASSISTED  DELIVERY  OF  THE  PLACENTA. 

or  be  rather  tardy;  I  have  already  pointed  out  the  duty  of  the 
accoucheur  in  the  first  instance,  and  the  mode  by  which  he  is  to 
execute  this  duty;  (556)  I  shall  therefore,  in  this  place,  only  con- 
sider what  is  to  be  done  in  the  latter  case. 

1203.  I  have  stated  in  effect,  (1200)  two  principal  causes  for 
the  tardy  separation  of  the  placenta:  namely,  1st.  A  diminution 
of  the  tonic  power;  and,  2d.  Too  great  a  firmness  in  the  connect- 
ing medium  of  this  mass  with  the  uterus;  each  of  which  requires 
a  little  difference  in  management.  The  first  of  these  may  be 
known:  1st.  By  the  uterus  being  rather  larger  and  softer  than 
it  sliould  be,  a  short  time  after  delivery;  2d.  By  no  portion  of 
this  mass  being  within  reach  of  the  finger  when  introduced  into 
the  vagina;  3d.  By  there  being  no  return  of  the  alternate  contrac- 
tions of  the  uterus;  and  4th.  When  a  force  is  applied  to  the  cord, 
it  gives  the  idea  that  the  placenta  is  descending;  but  this  being 
fallacious,  for  so  soon  as  we  cease  to  draw  upon  the  cord,  it  in- 
stantly mounts  again  into  the  pelvis. 

Sect.  I. — 1.  Mode  of  acting  iii  Retention  from  want  of  Tonic 
Power. 

1204.  When  this  state  of  things  presents  itself,  all  attempts  to 
deliver  the  placenta  must  be  forborne,  until  we  have  by  properly 
instituted  frictions  over  the  region  of  the  uterus,  obliged  it  to 
contract  and  harden  itself  under  the  hand;  and  at  the  same  time 
retire  lower  into  the  pelvis — when  these  alterations  show  them- 
selves, we  almost  always  find  they  will  be  accompanied  by  pain; 
and,  if  we  now  co-operate  in  a  proper  manner,  we  shall  find  the 
placenta  to  arrive  within  reach  of  the  finger,  and  announce  its  se- 
paration by  a  small  discharge  of  fluid  blood,  or  coagula,  or  both, 
and  fall  into  the  vagina,  from  whence  it  may  be  extracted,  as  has 
been  directed.  (556.) 

Sect.  II. — 2.  Retention  from  too  firm  adherence. 

1205.  In  the  second  case,  (1203)  we  shall  find  the  uterus  re- 
duced in  size;  firm  and  pretty  well  sunk  in  the  pelvic  cavity; 
and  may  be  even  attended  with  pain,  without  bringing  the  pla- 
centa within  reach  of  the  finger,  and  if  we  draw  upon  the  cord 
as  in  the  other  case,  there  is  little  or  no  retraction  after  we  inter- 
mit the  force. 

1200.  Tliis  case  requires,  for  the  separation  of  the  after- birth, 


ASSISTED  DEHVEKY  OE  THE  PLACENTA.  441 

not  only  a  firmer  contraction  of  the  uterus,  but  a  longer  continu- 
ance of  it;  as  well  as  a  particular  application  of  force  to  the 
placenta  itself,  by  means  of  the  cord.  Force,  to  be  successfully 
applied  for  the  separation  of  the  placenta,  must  be  directed  in 
such  a  manner,  as  to  act  perpendicularly  to  its  surface;  or  its  in- 
fluence will  be  destroyed — to  effect  this,  we  must  first  ascertain 
the  part  of  the  uteiois  to  which  this  mass  adheres.  This  is  to  be 
known  by  observing  the  part  of  the  pelvis  to  which  the  funis 
seems  inclined ;  as  this  will  point  out  the  portion  of  the  uterus  to 
which  the  placenta  is  adherent — thus,  if  the  cord  descend  behind 
the  symphysis  pubis,  the  placenta  vvill  be  attached  to  tlie  anterior 
part  of  the  uterus;  if  before  the  projection  of  the  sacrum,  it  will 
be  found  at  the  posterior  part  of  the  uterus  ;  if  to  either  side,  the 
placenta  will  be  at  the  side  on  which  the  cord  is  found. 

u.  Mode  of  acting  in  this  case. 

1207.  Having  ascertained  the  location  of  the  placenta,  we 
must  so  arrange  a  couple  of  fingers  within  the  vagina,  that  draw- 
ing the  cord  horizontally  will  act  in  the  desired  direction  upon 
it ;  that  is,  if  the  placenta  be  attached  to  the  anterior  portion  of 
the  uterus,  we  place  the  cord  behind  the  fingers,  and  press  it 
back  towards  the  projection  of  the  sacrum,  while  we  draw  the 
cord  with  the  other  hand  ;  if  to  the  posterior  portion,  we  place 
the  cord  before  the  fingers,  and  carry  it  as  high  as  we  can  well 
reach,  towards  the  superior  strait,  and  then  draw  with  the  other 
hand;  if  placed  at  the  lateral  portions,  we  must  introduce  the 
fingers  of  either  the  right  or  left  hand,  as  it  may  be  the  right  or 
left  side  of  the  uterus  to  which  the  placenta  is  attached,  and  then 
place  them  in  such  a  manner  that  the  horizontal  drawing  will  act 
in  a  proper  direction — if  the  placenta  be  at  the  left  side,  we  must 
introduce  the  fingers  of  the  right  hand,  and  vice  versa.  By  act- 
ing thus,  we  may  succeed  in  bringing  down  a  placenta,  which, 
without  it,  might  require  the  introduction  of  the  hand. 

120S.  In  this  situation  of  the  placenta,  (1203)  we  are  almost 
certain  to  have  the  co-operation  of  the  alternate  contractions  of 
the  uterus;  and  it  is  proper  that  we  take  advantage  of  them,  hy 
making  gentle  exertions  by  the  cord  at  the  same  time;  if  no  pain 
come  on,  we  should  solicit  the  farther  contractions  of  llie  ilterus, 
by  frictions  and  moderate  pressure  upon  it,  whiie  we  gently  and 
steadily  pull  at  the  cord.     We  should  now  and  then  ascertain  if 


442  ASSISTED  DELIVERY  OF  THE  PLACENTA. 

the  placenta  is  descending :  this  is  best  done  by  slacking  the  trac- 
tive force;  and  then  observe  whether  the  cord  remounts,  or  whe- 
ther it  remains  stationary.  If  it  ascend,  we  may  be  certain  that 
the  placenta  is  either  not  detached,  or  that  the  uterus  is  not  aiding 
in  its  expulsion — in  such  case,  we  should  be  very  careful  that  the 
degreeof  force  applied  to  the  cord,  be  not  sufficient  to  destroy  its 
union  with  the  placenta;  and  that  we  do  not  urge  its  deliverance 
too  importunately. 

1209.  If  we  find  the  cord  not  to  remount,  or  if  it  remount  but 
very  little  after  we  have  ceased  to  draw,  we  may  be  assured  the 
placenta  is  descending,  and  will  occupy  more  or  less  of  the  vagi- 
na; from  whence  it  may  be  easily  extracted,  as  it  is  now  within 
reach  of  the  finger. 

1210.  It  very  rarely  happens  that  the  introduction  of  the  hand 
is  necessary  to  deliver  the  placenta,  in  the  situations  I  have  just 
described;  method  and  address,  are  all  that  are  required  to  over- 
come the  existing  difficulties:  and,  perhaps,  there  is  no  other 
condition  of  this  mass,  in  which  it  has  been  so  often,  and  so  wan- 
tonly, dragged  from  the  uterus,  because  a  little  resistance  was  of- 
fered by  the  causes  just  stated.  It  would  seem  to  be  a  sufficient 
reason  with  very  many  inexperienced  practitioners,  to  introduce 
the  hand  for  the  delivery  of  the  placenta,  because  it  does  not  im- 
mediately precipitate  itself  into  the  vagina  after  the  birth  of  the 
child;  or  does  not  instantly  obey  the  force  that  is  applied  to  itj 
however  ill-directed,  or  inopportune,  that  attempt  may  be. 

1211.  Or  if  the  practitioner  be  timid,  and  obey  a  direction  but 
too  common  in  books  upon  this  subject,  that  a  certain  period  of 
time  must  elapse  before  any  attempt  be  made  to  deliver  the  pla- 
centa, he  may  let  the  proper  moment  elapse  for  the  successful  ap- 
plication of  a  well  directed  force,  and  thus  convert  a  case  of  great 
simplicity,  into  one  which  will  require  the  aid  of  art. 

1212.  I  say,  that  the  time  for  interference  of  the  accoucheur 
for  the  delivery  of  the  placenta,  should  always  be  regulated  by 
the  condition  of  the  uterus  itself;  and  that  condition  is,  when- 
ever it  is  firmly  contracted — this  rule  I  believe  will  never  de- 
ceive; or,  at  least,  I  have  uniformly  acted  upon  this  principle; 
and  so  far  I  think  I  am  safe  in  saying,  I  have  not  had  cause  to 
believQ  it  wrong.  I  acknowledge  that  some  address  is  required 
for  the  successful  delivery  of  this  mass  ;  but  as  this  is  easily  ac- 
quired by  a  proper  attention  to  the  laws,  by  which  it  is  ex- 
pelled,   I   should   hold    that   man   in   some   measure   accounta- 


ASSISTED  DELIVERV  OF  THE  PLACENTxV.  443 

ble,  if  he  produced  mischief,  by  an  improper,  or  ill-directed  ma- 
noeuvre. Time,  simply  considered,  can  never  form  a  safe  rule  for 
the  delivery  of  the  placenta;  the  degree  of  contraction  of  f/ie 
uterus,  alone,  can  point  out  the  proper  moment  to  operate,  or 
teach  us,  when  it  would  be  iinproper  to  attempt  it. 

1213.  I  am  decidedly  of  opinion,  that  the  necessity  for  artifi- 
cial delivery  of  the  placenta  is  often  created  by  obeying  a  rule 
taken  from  time,  let  that  period  be  longer  or  shorter;  for  time  in 
itself,  can  neither  produce  the  conditions  required,  nor  command 
them,  if  they  be  absent.  For  the  uterus  may  be  disposed  to  throw 
off  the  placenta,  and  it  would  do  so  if  properly  aided,  long  be- 
fore the  fixed  period  may  arrive;  or  it  may  be  in  a  state  of  such 
feebleness  at  that  moment,  as  to  render  it  highly  dangerous  to 
attempt  it — hence,  on  the  one  hand,  an  injury  may  be  done  to 
the  uterus  by  the  manual  delivery  of  the  placenta  by  the  resist- 
ance which  it  now  offers  to  the  attempt;  or  the  woman  be  ex- 
posed to  a  severe  and  perhaps  a  fatal  haemorrhage,  by  our  acting 
at  the  limited  moment;  it  is  therefore,  improper,  to  permit  the 
uterus  to  contract  by  improperly  delaying  the  moment  to  act,  so 
as  to  enclose  this  mass,  and  require  force  to  open  it;  or  by  inat- 
tention to  its  state  of  imperfect  contraction,  to  induce  a  flooding, 
by  acting,  because  a  specified  time  has  elapsed. 

1214.  Should  a  portion  of  the  placenta  be  separated,  and  a 
flooding  accompany  these  conditions  of  the  placenta,  it  must  be 
treated  as  directed  for  this  case.  (1147,  &c.) 

Sect.  III. — 3.  Of  the  Delivery  of  the  Encysted  Placenta. 

1215.  In  consequence  of  the  contraction  of  a  portion  of  the 
body  of  the  uterus,  before  the  placenta  is  delivered,  it  is  some- 
times confined  in  a  distinct  apartment,  as  it  were,  of  this  organ; 
and  this,  agreeably  to  my  own  experience,  is  always  at  the  fun- 
dus. The  mechanism  of  this  accident  is  easily  understood,  if  we 
recollect  the  strong  disposition  the  body,  and  especially  its  lower 
part,  has  to  contract,  or  narrow  itself,  w^hen  the  distending  cause 
is  removed;  and  especially,  while  the  placenta  remains  undeli- 
vered. 

1216.  Some  have  thought  this  contraction  could  take  place 
only  when  the  placenta  was  attached  to  the  side  of  the  uterus; 
and  others,  only  when  it  adhered  to  the  fundus;  of  this  last  opi- 
nion was  Baudelocque;  and  it  entirely  comports  with  my  own 
experience  of  this  condition  of  the  uterus— indeed  I  might  say 


444  ASSISTED  DELIVERY  OF  THE  PLACENTA. 

limited  cxjierience;  for  such  it  truly  is;  as  I  have  very  rarely  met 
with  it;  and  never,  so  far  as  my  recollection  may  be  depended 
upon,  when  I  have  had  the  entire  management  of  the  case.  Dr. 
Douglass,  of  Dublin,  has  considered  this  condition  of  the  uterus 
altogether  artificial;  or  arising  from  some  irritation  near  the 
mouth  of  this  organ ;  either  by  acting  upon  the  cord,  or  by  the 
introduction  of  the  hand. 

1217.  He  says,  "the  exciting  cause  of  the  uterus  assuming  the 
hour-glass  form  is  irritation,  produced  either  in  the  vagina  by  in- 
judicious pulling  at  the  umbilical  cord,  or  in  the  cervex  uteri,  by 
the  accoucheur's  hand,  searching  there  in  vain  for  the  placenta." 

1218.  "That  the  proximate  cause  is  a  spasmodic  constriction 
of  the  muscular  fibres  of  the  uterus  at  the  lower  verge  (not  the* 
centre),  of  that  section  termed  its  body,  and  just  where  it  ceases 
to  be  thickly  m.uscular." 

1219.  "  Thence  I  conclude,"  says  the  doctor,  "  that  this  hour- 
glass contraction  is  not  produced  by  any  principle  of  action  inhe- 
rent in  the  uterus  itself,  and  that  whenever  it  does  occur,  it  is 
caused  by  mismanagement." 

1220.  "  Therefoi'e,  in  order  to  avoid  such  occurrences,  the  prac- 
titioner should  always  refrain  from  exciting  unnecessary  irrita- 
tion." 

1221.  "  And  in  those  cases  of  unavoidable  retention  of  the  pla- 
centa, wherein  it  may  be  necessary  for  the  accoucheur  materially 
to  interfere,  he  should,  having  cautiously  inserted  it  within  the 
vagina,  push  his  hand  briskly  up  to  the  very  fundus  of  the  uterus. 
And  in  this  operation,  he  should  direct  the  hand  forward  towards 
the  umbilicus."  This  case  is  seldom  or  never  attended  b}' 
hsemorrhage.* 

1222.  This  case  may  be  known  by  the  fundus  of  the  uterus 
reaching  higher  than  common;  by  its  being  smaller  in  its  trans- 
verse direction,  as  can  be  detected  through  the  abdominal  parie- 
ties ;  by  an  elastic  feel  of  the  cord ;  by  no  pain  attending ;  by  the 
placenta  not  being  within  the  reach  of  the  finger;  and  if  upon  the 
introduction  of  the  hand,  the  cord  is  found  to  pass  through  an 
aperture  of  greater  or  less  size,  and  the  placenta  felt  to  lie  within 
the  cavity  formed  by  this  contraction. 

*  I  was  called  not  long  since  to  a  case  of  this  kind,  in  which  as  I  was  inform- 
ed by  the  gentleman  who  had  charge  of  the  case,  that  the  patient  had  suffered 
a  considerable  loss  of  blood — this  appeared  to  have  been  the  case,  as  I  found 
the  patient  was  very  much  exhausted  on  my  ai-nival — she  however  did  well. 


ASSISTED  DELIVERY  OF  THE  PLACENTA.  445 

a.  Mode  of  Ojocrating  in  iJiis  Case. 

1223.  In  the  hour-glass  contraction  of  the  uterus,  it  hecomes 
always  a  matter  of  necessity  to  operate,  and  this  should  be  under- 
taken so  soon  as  this  situation  is  ascertained;  as  I  believe  no  ad- 
vantage has  ever  been  derived  from  waiting.  It  is  in  vain  the 
action  of  the  uterus  is  solicited;  or  that  force,  however  well  direct- 
ed, be  applied  to  the  cord;  nothing  but  the  introduction  of  the 
hand,  and  that  made  to  pass  the  stricture,  can  relieve  the  placenta 
from  its  confinement. 

1224.  The  woman  should  be  placed  upon  her  back,  as  directed 
for  turning,  (732)  or  the  application  of  the  forceps;  (755)  the  hand 
must  be  cautiously  introduced  into  the  vagina,  and  forwarded 
agreeably  to  the  direction  of  the  cord,  which  should  be  taken  al- 
ways for  a  guide.  This  will  bo  found  passing  through  an  aperture 
of  uncertain  size;  sometimes  larger,  sometimes  smaller;  into  which 
the  fingers,  one  after  the  other,  must  be  introduced,  and  its  dilata- 
tion gradually  effected,  until  the  whole  hand  is  enabled  to  pass  the 
stricture.*  When  the  hand  has  possession  of  the  chamber  which 
contains  the  placenta,  this  mass  must  be  separated  carefully  if  it 
be  adherent,t  or  if  loose,  it  must  be  seized  with  sufficient  firmness 
to  secure  its  following  with  the  hand  when  this  is  withdrawn. 

1225.  Some  little  management  is  required  in  withdrawing  the 
placenta,  or  rather  in  the  mode  of  seizing  of  it — it  must  not  be 
grasped  by  the  whole  hand,  and  kept  in  it  by  contracting  the  fin- 
gers; for  its  bulk,  with  that  of  the  hand,  will  exceed  the  opening 
through  which  it  has  to  pass.  This  is  not  an  unusual  predicament, 
and  has  sometimes  been  attempted  to  be  overcome  by  force,  to 
the  discomfiture  of  the  operator,  and  to  the  serious  injury  of  the 
patient. 

1226.  During  the  introduction  of  the  hand  into  the  uterus,  and 

•  Wcdonotrecommeiidthedirectionjustgivcnby  Dr.  Douglass,  (1221)  "to 
push  the  hand  briskly  up  to  the  very  fundus  of  the  uterus."  On  the  contrary, 
tills  operation  should  be  deliberately  and  cautiously  performed,  or  much  mis- 
chief may  ensue;  for  such  is  the  resistance  sometimes  offered  by  the  constric- 
tion, that  it  would  rec[uire  much  force  to  overcome  it,  especially  if  it  be  sud- 
denly applied.  And  if  suddenly  applied  might  injure  the  connection  of  the  ute- 
rus with  the  vagina. — See  pal's.  1226,  1227. 

f  Dr.  Douglass  says,  it  is  always  found  adherent,  or  rather  that  it  is  never 
found  detached.  (Observations  on  the  hour-Glass  contraction  of  the  ifterus,  p.  10.) 
Dr.  .Ramsbotham  says,  that  it  is  generally  found  detached,  {Practical  Observa- 
tions, Am.  ed.  p.  144.)  and  this  comports  with  my  own  observations. 


446  ASSISTED  DELIVERY  OF  THE   PLACENTA. 

especially  while  contending  with  the  stricture,  the  uterus  must  he 
firmly  fixed  by  the  other  hand  being  pressed  upon  its  fundus,  un- 
til possession  is  taken  of  the  placenta,  and  the  hand  is  about  to  be 
\\  ilhdrawn.  After  the  after-birth  is  delivered,  I  have  thought  it 
best  to  re-enter  the  uterus  to  the  very  fundus,  so  as  to  be  certain 
that  neither  a  portion  of  the  placenta,  nor  coagula  are  left  be- 
hind. 

1227.  This  operation  is  always  to  be  slowly  and  cautiously  per- 
formed, as  the  woman  may  be  much  endangered  by  a  contrary 
practice — she  may,  by  rudeness  and  want  of  tact,  be  liable  to  sub- 
sequent inflammation  of  the  uterus,  or  its  immediate  rupture.  It 
is  to  the  patient  always  an  operation  of  severe  suffering,  however 
well-conducted,  unless  the  stricture  resists  but  very  moderately; 
therefore  to  add  to  it  by  rudeness  or  mal-adroitness,  is  both  cruel 


Sect.  IV. — 4.  On  the  enclosed  and jjartiaUy  lorotruded  Pla- 
centa. 

1228.  It  sometimes  happens  that  the  placenta  is  confined  in  the 
uterine  cavity,  though  detached  from  its  surface,  in  consequence 
of  the  sudden  contraction  of  the  mouth  of  the  uterus.  It  would 
perhaps  be  difficult  to  assign  the  reason  of  this  disposition  in  the 
mouth  of  the  uterus  to  close,  before  the  placenta  is  expelled — it 
may  arise  from  some  peculiar  stimulus,  or  from  some  preternatu- 
ral irritability  of  this  part  of  this  organ,  over  which  we  have  no 
control. 

1229.  This  situation  of  the  uterus  and  placenta  may  be  known, 
by  the  latter  being  unusually  long  detained,  when,  from  the  hard- 
ness and  well  contracted  condition  of  the  former,  we  should  not 
have  anticipated  such  delay;  by  the  force  applied  to  the  cord,  not 
making  the  placenta  descend;  by  an  absence  of  hsemorrhage; 
nay,  almost  of  discharge;  by  the  contracted  condition  of  the  os 
uteri,  by  the  placenta  being  felt  when  the  finger  is  passed  through 
it:  and  by  the  absence  of  pains. 

1230.  It  would  be  in  vain  to  attemptthedelivery  of  the  placen- 
ta by  any  exertion  made  upon  the  cord,  though  this  is  almost  al- 
ways resorted  to;  and  as  the  whole  of  the  uterus  will  sink  lower 
into  the  pelvis  by  this  effort,  the  inexperienced  practitioner  ima- 
gines that  the  placenta  is  descending — he  continues  his  traction 
under  this  illusion,  and  thinking  a  little  more  force  will  overcome 
the  difficulty,  he  multiplies  it;  the  cord  is  ruptured,  and  his  diffi- 


ASSISTED  DELIVERY  OF  THE  PLACENTA.  447 

culties  are  increased — he  now  becomes  alarmed ;  and  the  panic 
spreads  to  the  patient  and  her  friends  ;  everything  is  thi-own  into 
confusion ;  a  consuUation  is  demanded,  and  a  rival  practitioner 
robs  him  of  the  little  reputation  he  may  have  acquired,  and  thus 
interrupts  his  progress  in  business.  Or,  fearing  the  consequences 
a  discovery  of  this  accident  might  produce,  he  disengenuously 
conceals  it;  and  attempts,  without  method,  the  delivery  of  the 
imprisoned  placenta,  to  the  immediate  torture  and  the  subsequent 
injury,  of  his  patient — not  knowing  exactly  what  causes  the  delay, 
or  the  nature  of  the  difficulties  which  oppose  him,  after  ex- 
cruciating his  patient,  by  unavailing  efforts,  he  in  a  paroxysm 
of  mental  anguish,  abandons  her  and  declares,  the  case  must  be 
left  to  nature. 

1231.  The  modes  of  proceeding  in  such  cases,  are:  1st,  to  re- 
call the  contractions  of  the  body  and  fundus  by  the  exhibition  of 
the  ergot  in  common  doses ;  and  2d,  should  this  not  succeed  within 
an  hour,  the  uterus  must  be  gently  entered  by  slowly  dilating  the 
OS  uteri,  and  the  placenta  removed — this,  if  carefully  and  method- 
ically attempted,  is  not  so  difficult  as  might  at  first  be  imagined. 
The  woman  should  be  placed  as  directed  for  turning,  (732)  and 
during  the  passage  of  the  hand  through  the  os  uteri,  the  uterus 
should  be  firmly  supported  as  suggested.  (1226) 

1232.  I  have  ventured  to  suggest  the  exhibition  of  the  ergot  in 
this  case  rather  from  analogy,  than  experience — as  in  a  case  of 
retained  placenta,  after  a  premature  labour  of  the  seventh  month, 
and  another  under  similar  circumstances  at  the  sixth  month,  I 
happily  procured  the  expulsion  of  these  masses  by  this  remedy.* 

1233.  As  a  general  rule,  I  am  of  opinion,  that  the  sooner  we 
operate,  all  things  being  equal,  the  better,  as  the  obstinacy  of 
contraction  is  in  proportion  to  the  lapse  of  time,  unless  the  alter- 
nate contraction  of  the  uterus  come  in  to  our  aid. 

1234.  There  are  three  other  situations  of  the  placenta,  which 
may  be  regarded  as  varieties  of  this  case ;  the  first,  is  where  a 
small  portion  of  this  mass  is  pushed  through  the  os  uteri;  the  se- 

*  I  must  however  observe,  that  I  have  no  doubt  of  the  sufficiency  of  the 
«  Ergot"  to  procure  the  discharge  of  the  phicenta  after  the  birth  of  a  child  at 
full  time,  though  I  cannot  give  a  proof  of  it.  The  analogy  between  the  two 
cases  under  consideration,  is  too  strong  to  admit  a  doubt  upon  the  subject, 
though  the  occasions  for  the  employment  of  this  article,  will,  from  the  veiy 
nature  of  the  economy  of  the  uterus,  be  much  more  rare  in  cases  which  arrive 
at  fuU  time  than  those  in  which  dehvery  takes  place  prematurely. 


448  ASSISTED  DELIVERY  OF  THE  PLACENTA. 

cond,  is  where  about  one-half  has  escaped ;  the  third,  is  where 
the  greater  part  of  this  mass  is  without  the  mouth  of  the  uterus. 
In  all  these  instances,  the  farther  progress  of  the  placenta  is  pre- 
vented, by  the  os  uteri  firmly  embracing  it;  at  least  so  firmly,  as 
to  render  the  attempt  to  relieve  it  by  the  cord,  not  only  fruitless, 
but  perhaps  mischievous,  by  causing  its  rupture. 

Mode  of  acting  in  each  case. 

1235.  If  the  placenta  be  found  in  the  first  situation  enumerated, 
(1234)  we  may  procure  its  descent,  by  employing  the  crotchet 
recommended  for  the  delivery  of  this  mass,  in  cases  of  flooding 
from  abortion,  (see  figure  in  Treatise  on  Diseases  of  Females, 
chapter  on  uterine  haemorrhage,  by  the  author,)  or  by  dilating 
the  OS  uteri  as  recommended,  (1224)  first  pushing  up  the  protrud- 
ing portions. 

1236.  For  the  second  condition,  the  hand  must  be  introduced 
into  the  vagina,  and  a  finger  passed  under  the  edge  of  the  os  uteri, 
by  which  successive  portions  of  the  placenta  must  be  hooked  and 
brought  downward,  until  the  whole  is  relieved. 

1237.  In  the  third  instance,  all  that  is  required  is,  the  intro- 
duction of  the  hand  into  the  vagina,  and  the  firm  seizure  and 
compression  of  the  placenta,  as  near  the  os  uteri  as  possible;  com- 
pression near  the  stricture,  diminishes  the  bulk  of  the  placenta  so 
much,  as  to  permit  it  to  escape,  by  drawing  the  whole  mass  to- 
ward the  OS  externum. 

123S.  The  cases  T  have  just  described,  are  far  from  being  un- 
common; and  few,  offer  greater  embarrassment  to  the  inexperi- 
enced practitioner.  The  cause  of  the  detention  of  the  placenta 
in  many  cases  is  not  sufficiently  well  understood,  or  sufficiently 
early  ascertained,  to  render  them  free  from  risk — I  therefore, 
recommend  to  the  young  practitioner,  to  search  for  this  mass 
whenever  any  unusual  delay  in  its  delivery  takes  place,  though 
the  case  be  not  attended  by  flooding,  or  other  accident,  provided, 
he  has  previously  put  in  practice  all  the  means  which  are  usually 
essential  to  its  expulsion,  and  they  have  failed;  or,  having  waited 
until  the  condition  of  the  uterus,  as  ascertained  by  the  hand 
through  the  abdominal  parietes,  gives  evidence  that  it  has  con- 
tracted sufficiently,  if  not  successfully.* 

*  For  the  mode  of  actinjj  in  "  placental  presentations;"  under  all  their  vari- 
ous forms,  see  Chapter  on  "Unavoidable  Iliemorrhag-e;"  for  the  plan  of  proceed- 


ASSISTED  DELIVERY  OF  THE  PLACENTA.  449 

Sect.  V.— 5.  Of  the  Delivery  of  the  Placenta,  ivhen  the  Cord 
is  broken  or  is  very  feeble. 

1239.  An  undue  force  applied  to  the  cord  with  a  view  to  de- 
liver the  placenta,  may  rupture  the  funis;  hence,  the  important 
caution,  of  not  applying  too  much.  It  sometimes  happens,  how- 
ever, that  a  very  moderate  force  will  destroy  its  connection  with 
the  placenta — this  may  arise  from  a  weak  state  of  this  production, 
though  it  may  be  sound;  it  may  arise  from  a  morbid  condition 
of  it;  or  from  its  being  in  a  state  of  putrefaction. 

1240.  Those  who  are  in  the  habit  of  seeing  many  cases  of 
midwifery,  can  pretty  well  judge  of  the  firmness  or  strength  of 
the  cord,  so  soon  as  they  see  it;  and  will  regulate  their  endea- 
vours to  extract  the  placenta  by  it.  When  the  funis  is  frail,  or  ve- 
ry tender,  it  should  never  be  used  as  a  means  to  deliver  the  after- 
birth; it  should  always  be  preserved  as  a  guide  for  the  hand, 
should  it  become  necessary  to  enter  the  uterus.  The  rupture  of 
the  cord  in  itself,  does  not  necessarily  create  difficulty;  since,  if 
this  part  be  very  delicate,  we  do  not  employ  it  in  our  attempts, 
to  free  the  uterus  of  the  placenta— therefore,  in  such  cases,  the 
placenta  derives  no  advantage  from  its  preservation,  as  regards 
its  unaided  delivery;  but  it  may  be  of  important  service,  should 
it  be  necessary  to  relieve  it  by  the  hand. 

1241.  It  \\\\\  follow  from  what  has  been  said,  (1240)  that 
it  is  not  always  necessary  to  make  an  artificial  case  of  a  rup- 
tured cord;  for  the  expulsion  of  this  mass  is  nowise  promo- 
ted by  its  preservation,  if  the  cord  be  too  feeble  to  act  with 
it;  delivery,  therefore,  in  such  case,  must  depend  upon  the 
.spontaneous  efforts  the  uterus  makes  to  clear  itself  of  this 
burthen,  and  not  upon  any  force  that  may  be  applied  to  the 
funis. 

1242.  But,  though  the  preservation  of  the  cord  may  not  aid  us 
in  our  attempt  to  deliver  the  placenta  when  it  is  too  tender  to 
be  an  agent,  yet  it  is  highly  important,  notwithstanding,  that  it 
should  be  carefully  preserved;  especially  as  we  cannot  determine 
a  priori,  the  cases  in  which  it  may  be  necessary  to  deliver  this 

ing  in  hsmorrhagy  from  a  partial  separation  of  the  placenta;  for  the  rule  of 
conduct  where  it  is  too  adherent,  and  attended  by  flooding;  for  rules  to  be  ob- 
served, in  hemorrhage  from  atony  of  the  uterus  after  separation  of  the  placen- 
ta; &c.  see  Section  oil  "Hemorrhage  before  the  placenta  is  expelled,"  &c. 
57 


450  ASSISTED  DELIVERY  OF  THE  PLACENTA. 

mass,  artificially;  for,  during  its  continuance  within  the  uterus, 
some  accident  may  attack  the  patient,  and  render  it  indispensa- 
bly necessary  to  interfere  and  hasten  its  delivery. 

1243.  It  may,  however,  be  remarked,  as  a  general  rule,  that 
the  placenta  is  longer  in  descending  when  we  cannot  aid  it  by  the 
the  cord,  or  when  the  cord  is  separated  from  it,  than  when  it  is 
strong  and  preserved — the  reason  is  obvious.  We  should,  there- 
fore, in  such  cases,  promote  the  contraction  of  the  uterus  by  fric- 
tions; and,  from  what  I  have  experienced  of  the  action  of  the  er- 
got, (1221)  1  should  be  induced  to  give  it  a  trial  before  I  would 
pass  the  hand  into  the  uterus;  for  the  hand  should  not  be  intro- 
duced until  it  has  been  satisfactorily  proved  that  the  ergot  had 
failed. 

1244.  Should  we  not  succeed  by  these  means  in  relieving  the 
uterus  of  its  burthen;  and,  especially,  should  any  accident  com- 
plicate this  period  of  labour,  we  must  introduce  the  hand,  and  de- 
liver the  placenta.  The  difficulty  in  this  case  is  no  greater  than 
in  common  cases,  provided  the  cord,  (however  feeble  it  may  be,) 
is  preserved,  since  this  will,  with  proper  management,  conduct  us 
to  the  placenta,  as  certainly  as  a  stronger  one — but  if  it  be  sepa- 
rated, a  great  deal  of  embarrassment  may  be  sometimes  created, 
by  not  being  able  to  distinguish  the  placenta  from  the  uterus,  if 
this  mass  be  not  detached;  if  it  preserve  its  connection  with  the 
uterus,  the  unskilled  hand  will  find  much  difficulty  in  distinguish- 
ing it  from  the  surface  of  this  organ. 

a.  The  Si'gjis  hy  which  the  Placenta  may  he  detected. 

1245.  The  following  marks  will,  however,  lead  to  the  detec- 
tion of  the  placenta;  1st.  If  the  fingers  pass  over  the  internal  sur- 
face of  this  body,  its  vessels,  distended  by  blood,  will  generally 
be  distinctly  felt;  2d.  If  the  placenta  be  pressed  by  the  fingers,  the 
woman  will  scarcely  perceive  their  presence;  whereas,  if  the 
uterus  be  touched,  she  will  complain;  3d.  If  the  hand  be  placed 
over  the  uterus,  externally,  opposite  the  one  within  the  uterus, 
the  thickness  of  the  parts  will  declare,  whether  it  be  the  placenta 
which  interposes  between  them,  when  this  mass  is  on  the  ante- 
rior part. 

h.  The  mode  of  acting  in  this  case. 

1246.  When  it  is  ascp"tained  that  the  hand  is  in  contact  with 


ASSISTED  DELIVERY  OF  THE  PLACENTA.  45). 

the  placenta,  the  latter  must  be  cautiously  separated  from  the 
uterus,  by  insinuating  the  fingers  between  them.  There  is  some- 
times a  difficulty  in  getting  behind  the  placenta,  in  consequence 
of  the  membranes  interposing  between  the  hand  and  the  surface 
of  the  uterus.  To  overcome  this  hinderance,  the  hand  should  be 
placed  behind  the  membranes,  and  then  permitted  to  travel  up 
to  the  placenta  itself,  and  effect  the  separation. 

1247.  Should  the  placenta  be  found  loose  in  the  uterus,  it 
must  be  taken  hold  of  and  withdrawn. 

1248.  I  have  a  few  times  met  with  difficulty  in  the  delivery 
of  the  placenta  from  its  excessive  size.  These  instances  have 
uniformly  occurred  in  cases  of  permature  delivery,  or  rather 
where  the  delivery  was  not  premature,  but  where  the  child  had 
died  some  time  before  its  birth.  In  the  particular  cases  alluded 
to,  the  children  were  not  found  putrid;  but,  on  the  contrary, 
were  hard  and  rigid,  though  a  little  swoln;  the  funes  were  always 
much  enlarged,  very  tender,  and  engorged  with  a  brown  blood; 
the  placentas  were  found  in  these  cases  to  distend  the  uterus  so 
much,  as  to  give  the  suspicion,  to  those  unacquainted  with  the 
nature  of  such  cases,  that  there  was  a  child  remaining  in  the 
uterus. 

1249.  In  looking  over  my  records  of  these  cases,  I  do  not  find 
one  that  did  not  require  the  introduction  of  the  hand  for  its  de- 
liverance; and,  in  two  of  these,  the  placentae  were  so  enormously 
large,  as  to  nearly  fill  a  common-sized  chamber  pot.  This  pro- 
digious increase  appeared  to  be  owing  to  the  infiltration  of  water 
into  the  meshes  of  the  placenta.  In  all  the  cases  of  the  kind  now 
under  consideration,  no  aid  was  derived  in  the  delivery  of  the 
placentae  from  the  funes,  as  they  were  uniformly  found  so  frail 
as  to  not  permit  any  force  to  be  applied  to  them. 


(     452     ) 


CHAPTER  XXXIIL 

OF  PUERPERAL  CONVULSIONS. 

1250.  This  truly  frightful  disease  may  attack  a  woman,  per- 
haps, at  any  period  of  utero-gestation;  but  more  frequently  after 
the  sixth  month.  Dr.  Lyman  says,  "  it  seems  to  be  a  question 
with  some  writers,  whether  the  disease  we  are  considering,  ever 
attacks  antecedently  to  labour.  I  believe,  we  may  very  safely 
answer  this  in  the  affirmative.  I  do  not  recollect  having  seen  it 
earlier  than  the  latter  part  of  the  seventh  month."* 

1251.  I  do  not  recollect  at  this  moment  having  met  with  any 
writer  who  has  questioned  the  liability  of  the  pregnant  woman  to 
convulsions.  I  am  certain  this  opinion  must  be  wrong,  as  I  have 
witnessed  a  number  of  cases  of  convulsions  where  labour  was  not 
present,  and  where  there  was  no  reason  to  believe  this  process 
had  any  agency  in  their  production.  That  women  are  much  more 
liable  to  this  disease  when  this  process  is  about  to  commence;  or 
after  it  has  advanced,  is  agreeable  to  all  observation;  and  that 
labour  frequently  follows  a  few  days  after,  as  Dr.  Lyman  ob- 
serves, is  equally  true:  for  we  believe  with  him,  that  the  partu- 
rient effort  has  very  often,  either  a  direct  or  indirect  agency  in 
their  production;  or  in  other  words,  is  the  exciting  cause.  The 
causes  assigned  for  convulsions  have  been  various;  some  have 
supposed  they  arise  from  some  peculiar  irritation  of  the  uterine 
fibre  from  pregnancy;  others  considered  them  truly  epileptic; 
while  others  regard  them  as  nervous,  or  hysterical. 

1252.  This  difference  in  views,  necessarily  leads  to  a  difference 
in  treatment — the  first,  makes  safety  consist  alone  in  immediate 
delivery;  the  second,  forbids  the  practice;  while  the  third,  relies 
upon  the  use  of  opium.  From  what  I  have  seen  of  this  formida- 
ble complaint,  I  am  persuaded,  that  there  is  no  one  cause  con- 
stantly operating  to  produce  puerperal  convulsions;  nor  is  there 
any  one  mode  of  cure  applicable  to  all  cases.  To  be  successful 
in  the  management  of  this  complaint,  it  is  necessary  that  at- 
tention be  paid  to  the  species  of  this  disease,  with  which  the 
woman  may  be  attacked;  I  have,  therefore,  from  a  conviction 

*  New  England  Journal,  No.  IV.  >'ol.  III.  third  Series,  p.  344. 


PUERPERAL  CONVULSIONS.  453 

that  they  do  not  all  depend  upon  one  and  the  same  cause,  divided 
them  into;  first,  epileptic;'  second,  apoplectic;  and  third,  into 
the  hysterical;  each  of  which  may  attack  under  two  distinct  con- 
ditions of  the  uterus,  and  requiring  from  that  circumstance  a  dif- 
ference of  management. 

1253.  Convulsions  are  almost  always  preceded  by  symptoms 
which  denote  their  approach;  in  the  epileptic  species,  the  premo- 
nitory symptoms  may  exist  a  number  of  days  before  convulsions 
show  themselves;  it  is  uniformly  attended  by  a  strong  determina- 
tion to  the  head,  producing  an  engorgement  of  the  vessels;  hence, 
head-ache  of  greater  or  less  intensity,  ringing  of  the  ears,  a  tem- 
porary loss  of  vision,  giddiness,  &c.  are  alwayspresent  before  the 
convulsive  stage  shows  itself.  From  these  symptoms  being  fol- 
lowed by  convulsions,  I  have  always,  when  consulted  upon  such 
occasions,  advised  the  immediate  loss  of  blood,  pretty  smart  purg- 
ing, and  an  abstemious  diet.  By  thus  anticipating  the  attack,  I 
feel  assured  I  have  in  a  number  of  instances  prevented  this  terri- 
ble disease. 

1254.  Some  are  attacked  by  a  severe  pain  in  the  stomach,  which 
Dr.  Denman  considers  as  more  fatal  than  when  the  head  is  the 
seat  of  pain;  of  this  I  can  say  nothing  from  my  own  experience. 
I  may  remark,  that  the  longer  the  premonition,  the  milder  the 
attack  appears  to  be.  In  the  most  suddenly  fatal  case  I  ever  saw, 
the  patient  suddenly  cried  out,  "  my  head,  my  head!"  convulsions 
instantly  ensued,  of  which  she  died  in  a  few  hours — See  Case  IV. 

1255.  Pregnant  women  may  be  attacked  with  convulsions  from 
causes  not  connected  with  gestation,  or  at  least  with  labour — as 
the  attack  is  not  accompanied  with  any  signs  of  it.  These,  if  my 
observations  be  correct,  are  more  unmanageable  and  fatal,  than 
when  pregnancy  may  be  the  remote  cause.  When  pregnancy  is 
instrumental  in  the  production  of  convulsions,  it  is  almost  always 
at  that  period,  when  the  uterine  fibres  are  at  their  greatest  stretch; 
where  the  os  uteri  is  disposed  to  dilate;  or  where  they  suffer  from 
some  peculiar  irritation,  over  which  we  have  no  control;  or  some 
inconvenience  from  the  contents  of  the  uterus,  which  has  the  same 
effect;  and  such  convulsions  are  almost  always  of  the  epileptic 
species. 

1256.  These  convulsions,  so  far  as  my  observations  have  ex- 
tended, are  never  preceded  by  an  aura,  as  in  epilepsy,  properly 

•  We  do  not  pretend  by  this  term  to  insist  on  its  character  being  the  same  as 
in  true  epilepsy— the  term  is  only  adopted,  from  the  want  of  one  more  strictly 
perhaps  appropriate. 


454  PUERPERAL  CONVULSIONS. 

SO  called.  But  after  the  patient  has  suffered  for  a  longer  or  short- 
er period  the  symptoms  just  named,  (1253)  she  is  seized  with 
quickl}^  repeated  spasms — the  face  and  eyes  are  twitched  in  all 
possihle  directions,  with  incredible  quickness — the  arms,  legs,  nay, 
the  whole  body,  is  violently  agitated — one  side  is  sometimes  more 
affected  than  the  other;  the  face  becomes  flushed,  livid,  black; 
the  tongue  is  strongly  thrust  forward  between  the  teeth,  by  which 
it  is  almost  always  severely  wounded.  Respiration  at  first  is 
much  hurried,  and  eventually  becomes  almost  suspended;  the  ca- 
rotids beat  violently;  the  jugulars  are  much  distended;  a  pecu- 
liar sibilating  noise  is  made  by  the  mouth,  not  unlike  what  Is 
termed  "  a  cat  spitting;"  froth  issues  from  the  mouth,  tinged  with 
blood  from  the  wounded  tongue.  The  pulse  in  the  beginning  is 
full,  frequent,  and  tense;  but  quickly  becomes  rapid,  small,  and 
eventually  almost  imperceptible;*  the  urine  and  fasces  are  some- 
times discharged  involuntarily;  a  cold  clammy  sweat  bedews  the 
whole  body,  and  the  fit  begins  now  to  decline. 

1257.  The  convulsive  motions  gradually  subside — they  never 
cease  suddenly  and  at  once — their  force  and  frequency  abate; 
the  pulse  becomes  more  distinct  and  less  frequent;  the  breathing 
is  less  hurried,  and  less  oppressive;  the  face  loses  part  of  its  lividi- 
ty;  the  muscles  are  agitated  but  at  intervals,  and  their  action  re- 
sembles the  commotion  excited  by  passing  a  brisk  electric  shock 
through  them,  and  eventually  they  sink  into  repose.  The  patient, 
however,  remains  for  the  most  part  insensible  or  comatose,  with 
stertorous  breathing  or  loud  snoring;  she  cannot  be  roused  by  any 
exertion  for  some  time,  and  if  she  recover  for  a  moment  her 
scattered  senses,  she  is  without  the  slightest  recollection  of  what 
has  passed.  This  truce  is  almost  always  of  short  duration;  con- 
vulsion follows  convulsion,  without  our  being  able  to  determine 
the  period  or  cause  of  their  return. 

1258.  When  convulsions  attack  a  woman  absolutelyjn  labour? 
or  when  this  is  about  to  take  place,  we  may  observe  a  pretty  re- 

*  I  do  not  remember  to  have  witnessed  .the  condition  of  the  system  mention- 
ed by  Dr.  Lyman;  namely,  "oedema,  and  a  remarkable  slowness  of  pulse  as  the 
precursors  of  convulsions,"  p.  347.  I  have  often  remarked  the  bloatedface  after 
the  attack,  but  never  an  cedematous  condition  of  the  system  previously  to  it.  Not 
that  this  condition  of  the  system,  especially  of  the  lower  extremities  is  uncom- 
mon, but  that  I  have  never  found  those  who  were  subject  to  it,  more  liable  to 
the  attack  of  convulsions  than  those  in  whose  system  this  condition  did  not  ob- 
tain. Indeed,  it  would  seem  that  tliey  should  be  less  obnoxious  to  it,  as  this 
class  of  females  arc  rarely  so  plethoric  as  others,  as  effusion  in  the  cellular  tissue 
seems  to  relieve  this  over-fulness. 


PUERPERAL  CONVULSIONS.  455 

gular  occurrence  of  the  fits  with  the  probable  return  of  the  pains 
— for  though  the  patient  be  insensible  to  external  occurrences, 
she  appears  to  manifest  by  her  moans,  and  the  suspension  of  re- 
spiration, her  sensibility  to  uterine  contraction.  This  appears  to 
me  to  be  so  manifest  and  decided,  that  I  think  I  could  tell  what 
is  going  on  at  the  mouth  of  the  uterus,  without  an  examination 
per  vaginum. 

1259.  The  face  becomes  very  much  swoln,  especially  the  lips 
and  eyelids;  indeed  the  whole  body  seems  to  partake  in  a  greater 
or  less  degree  of  this  intumescence,  but  in  no  part  so  conspicu- 
ously as  the  face.  So  completely  is  the  countenance  changed,  or 
rather  disfigured,  that  oftentimes  it  could  not  be  recognized  by 
the  dearest  or  most  intimate  friend;  nor  does  this  swelling  im- 
mediately subside  with  the  convulsions  which  caused  it;  it  fre- 
quently remains  many  days  after  they  have  ceased.  Dimness  of 
sight,  nay,  blindness  for  weeks,  are  not  unusual  consequences  of 
this  disease. 

1260.  In  the  apoplectic  species  we  have  nearly  all  the  premo- 
nitory symptoms  enumerated  above,  (1253)  but  of  much  shorter 
duration.*     It  may,  like  the  epileptic,  attack  at  any  period  of 

*  In  a  case  of  this  species,  which  fell  under  my  notice  some  time  since,  I 
thought  it  was  not  accompanied  by  either  as  much  frothing  at  the  mouth,  or 
with  as  much  sibilation,  as  in  the  epileptic.  Mrs.  ,  aged  seventeen,  preg- 
nant with  her  first  cluld,  complained,  on  the  20th  of  July,  1824,  of  slight  pains 
resembhng  labour;  and  also  a  general  diffused  pain,  but  severest  in  her  limbs; 
so  much  so,  in  these  parts,  as  to  render  her  almost  incapable  of  moving  them; 
some  fever,  though  slight.  Dr.  Shaw,  under  whose  care  she  was,  ordered  her 
to  be  bled  and  purged.  29th,  3  o'clock  A.  M.  was  attacked  witii  labour  pains; 
.at  first  they  were  slight;  but  had  much  increased  by  the  time  tlie  doctor  was 
called.  Upon  examination,  the  os  uteri  was  found  a  little  opened;  and  at  8 
o'clock  A.  M.  was  attacked  with  strong  convulsions,  which  were  repeated 
about  every  twenty  minutes.  She  was  bled  about  twenty  ounces;  convulsions 
continued  to  recur.  At  10  o'clock  the  same  morning,  the  os  uteri  was  pretty 
well  dilated;  and  from  a  belief  that  convulsions  were  at  least  maintained  by 
uterine  distention  and  irritation.  Dr.  Shaw  ruptured  the  membranes,  with  a 
hope  of  tranquillizing  them. 

At  tliis  time,  I  was  called  in.  I  found  the  patient  totally  insensible  to  any 
external  impressions;  nor  had  she  discovered  any  sensibility  after  the  second 
fit;  breathing  with  considerable  difficulty,  and  snoring  pretty  loud.  The  pulse 
was  full,  frequent,  and  hard,  and  the  skin  hot.  Upon  examining  per  vaginam, 
tlie  liead  of  the  child  was  found  at  the  lower  strait,  presenting  with  the  poste- 
rior fontanelle  behind  the  left  foramen  ovale,  and  entirely  witliin  the  uterus— 
up  to  this  time,  about  thirty -five  ounces  of  blood  were  drawn.  She  was  attack- 
ed with  a  fit  soon  after  examination.  There  was  something  remarkable  in  the 
character  of  her  convulsions — her  eyes  were  but  little  agitated :  tlie  pupils  much 


456  PUERPERAL  CONVULSIONS. 

gestation,  but  does  not  always  necessarily  produce,  or  be  accom- 
panied by  labour.  From  this,  it  would  appear  it  may  be  brought 
on  by  causes  independent  of  pregnancy,  though  this  process  may 
with  propriety  be  regarded  as  an  exciting  cause;  for  it  sometimes 
takes  place  when  this  process  is  at  its  height,  and  labour  is  no 
otherwise  accessary  to  this  end,  than  increasing  by  its  efibrts,  the 
determination  of  blood  to  the  head.  This  species  may  perhaps 
■with  much  propriety,  be  considered  only  an  exalted  degree  of 
the  epileptic — in  this,  the  epileptic,  there  is  perhaps  only  engorge- 
ment; in  the  other,  there  is  almost  constantly  efiusion. 

1261.  In  the  hysterical  species,  we  have  not  the  same  train  or 
continuance  of  the  premonitory  symptoms.  If  head-ache  attend, 
it  is  neither  so  severe  nor  so  permanent;  there  is  a  ringing  in  the 
ears,  globus  hystericus,  and  palpitation  of  the  heart.  The  face  is 
much  less  convulsed — less  vacillation  of  the  eyes,  while  the  larger 
muscles  of  the  body  are  much  more  violently  agitated;  the  pa- 
tient, at  times,  is  very  obstreperous:  and  the  muscles  on  the  pos- 
terior part  of  the  body  are  almost  always  violently  contracted ; 
so  much  so,  that  the  body  will  sometimes  describe  an  arch  back- 
ward. I  have  considered  this  last  circumstance,  as  strongly 
marking  this  species  of  convulsion.  The  face  is  much  less  flush- 
ed, than  eiiher  of  the  two  other  species ;  but  never  pale,  agree- 
ably to  my  observations,  as  some  have  remarked."* 

1262.  There  is  no  frothing  at' the  mouth;  and  the  peculiar 
sibilating  noise  which  so  strongly  characterizes  the  first,  and  per- 
haps the  second  species,  is  entirely  wanting  in  this — the  patient, 
after  the  fit  can,  for  the  most  part,  be  roused  to  attention,  or  will 
frequently  become  coherent,  so  soon  as  she  recovers  from  the 

contracted;  hei'  face  was  but  little  suffused;  there  was  less  frotliing  at  the 
moutli,  and  less  sibilation  tlian  is  usual. 

I  applied  the  forceps,  and  deUvered  her  in  a  few  minutes  without  the  slight- 
est difficulty.  She  remained  after  this  for  two  hours  without  a  fit;  at  the  expi- 
ration of  this  time,  they  recurred  about  every  half  horn-,  until  nine  o'clock,  P.  M. 
when  they  ceased,  but  without  any  amendment  in  the  condition  of  the  patient — 
she  appeared  completely  apoplectic.  She  continued  much  in  this  situation  until 
six  o'clock  in  the  evening  of  the  31st,  at  wh'ch  time  she  died.  Leave  could  not 
be  obtained  to  inspect  the  body.  She  did  not  complain  of  head-ache  until  the 
29th,  and  this  but  a  short  time  before  she  became  con\'ulsed.  She  lost,  alto- 
gether, eighty -two  ounces  of  blood;  was  freely  purged,  and  once  cupped. 

*  Dr.  Lyman  says,  "it  is  particulai-ly  important  that  we  should  know  how  to 
distinguish  puerperal  convulsions  from  such  as  are  purely  hysterical."  p.  351.  In 
this  1  fuUy  agi-ec;  and  I  should  have  felt  grateful,  had  he  added  to  our  know- 
ledge in  diagnosis,  by  observations  of  his  o\\  n.  He  has  however,  laid  down  no 
mai-ks  by  which  we  can  distinguish  one  species  from  the  other. 


PUERPERAL  CONVULSIONS.  457 

fatigue  or  exhaustion  occasioned  by  the  violence  of  her  struggles; 
and,  though  she  may  lie  apparently  stupid,  she  will,  nevertheless, 
sometimes  talk,  or  indistinctly  mutter.  After  the  convulsion 
has  passed  over,  she  will  often  open  her  eyes,  and  vacantly  look 
about;  and  then,  as  if  suddenly  seized  by  a  sense  of  shame,  will 
sink  lower  in  the  bed  and  attempt  to  hide  her  head  under  the 
clothes.  The  pulse  is  much  less  disturbed,  nor  does  it  ever  ac- 
quire that  extreme  velocity  and  tenuity  it  does  in  the  other  two 
species,  for  respiration  is  never  so  much  in  danger  of  being  sus- 
pended.* 

1263.  This  species  attacks  women  of  delicate  and  nervous  ha- 
bits; the  recovery  from  it  is  always  more  rapid,  and  never,  so 
far  as  I  have  observed,  leaves  any  imperfection  of  vision. 

1264.  As  nothing  is  so  satisfactory,  as  regards  the  application 
of  remedies  for  any  disease,  as  the  detail  of  cases,  in  which  their 
routine  is  exhibited,  I  shall  make  no  apology  for  inserting  the 
following  from  my  "Essay  on  Puerperal  Convulsions."  See 
"Essays  upon  various  Subjects  connected  with  Midwifery." 

Case  First. 

Mrs. ,  a  delicate  small  v/oman,  twenty-three  years  of  age, 

pregnant  with  her  first  child,  was  attacked,  on  the  16th  of  No- 
vember, 1809,  at  8  o'clock,  A.  M.  with  epileptic  convulsions.  I 
saw  her  in  an  hour  after  the  attack;  previously  to  my  seeing  her, 
she  had  had  three  fits,  and  a  fourth  was  coming  on  just  as  I  en- 
tered the  door.  Three  or  four  days  previously  to  the  attack,  she 
complained  of  a  violent  jaw  or  tooth-ache,  which  was  looked 
upon  as  rheumatic,  and  no  attention  was  paid  to  it.  On  the  15thj 
that  is,  the  day  before  her  illness,  she  was  seized  with  an  extreme- 
ly acute  head-ache;  and,  during  the  night,  and  just  before  the 
onset  of  the  fits,  she  was  violently  sick  at  stomach,  and  vomited 
a  large  quantity  of  thick  glairy  mucus;  immediately  after  this 
she  said  she  could  not  see,  and  was  in  a  few  minutes  more 
seized  with  convulsions.     She  laboured  under  these  violent  and 

*  Doctor  Lyman  says,  "every  variety  of  the  disease  is  to  be  regarded  as 
dang-erous;  for  though  a  patient  should  appear  but  slightly  injured  by  the  first 
attack,  a  subsequent  one  may  prove  suddenly  fatal."  p.  350,  loc.  cit.  I  have 
never  seen  death  follow  the  hysterical  species;  though  the  convulsions  may  have 
been  very  violent.  Nay,  females  who  are  subject  to  this  afteclion,  are  some- 
times occasionally  affected  with  convidsions  during  the  whole  period  of  utero- 
gestation,  and  this  without  disturbing  its  economy — the  same  may  be  said  of 
constitutional  epilepsy. 
58 


458  PUERPERAL  CONVULSIONS. 

terrific  symptoms  in  an  extreme  degree.  I  instantly  bled  her 
from  a  large  orifice  in  the  arm  3xxxv.  by  measure;  this,  as  I 
have  just  said,  was  at  9  o'clock  A.  M.  Eleven  o'clock,  had  two 
fits  during  my  absence,  and  was  now  in  the  tliird — bled  5xii. 
Ordered  a  strong  infusion  of  senna  as  an  enema — os  tincse  a  little 
opened,  but  rigid.  One  o'clock,  P.  M.,  had  two  fits  since  last 
visit — injection  operated — pulse  still  active — face  flushed — very 
restless  and  uneasy,  arising,  as  I  believe,  from  the  pains  in  the 
uterus — OS  tincse  rather  more  dilated — to  be  bled  by  cups  ^x. 
Four  o'clock,  P.  M.,  one  fit;  cups  drew  well;  senna  operated  again 
two  or  three  times;  very  comatose — ordered  cold  applications  to 
the  head  by  means  of  a  large  bladder,  partly  filled  with  water 
and  some  ice — blisters  to  the  legs.  Seven  o'clock,  P.  M.,  no  fit 
since  last  visit — pulse  very  active — very  restless,  constantly  mak- 
ing efforts  to  get  out  of  bed* — os  tineas  not  much  more  dilated; 
took  5X.  blood;  senna  continued  to  operate.  Ten  o'clock,  P.  ^I., 
no  fit  since  last  visit;  pulse  still  too  active;  took  5X.  more  of 
blood ;  cold  applications.  Seventeenth,  Mr.  Purnell,  now  Dr. 
Purnell,  one  of  my  pupils,  staid  all  night  with  the  patient.  He 
said  she  had  one  fit,  after  which  he  took  fx.  of  blood;  senna  con- 
tinued to  operate.  At  10  o'clock,  A.  M.  I  saw  her;  stupor  much 
less;  recognized  her  friends,  and  asked  some  questions;  she  did 
not  see  well,  a  slight  squinting  was  observable.  Seven  o'clock 
P.  M.  better,  pulse  less  active;  but  had  three  stools  since  the 
morning  visit.  Eighteenth,  Mr.  de  la  Motha,  now  Dr.  de  la 
Motha,  another  of  my  pupils,  staid  with  the  patient  last  night. 
She  passed  a  good  night,  was  tranquil  and  rational;  no  return  of 
fits  during  the  night;  two  stools.  Saw  her  at  10  o'clock,  A.  M., 
skin  dry  and  hot,  face  a  little  swelled,  but  perfectly  collected. 
Eight  o'clock,  P.  M.,  face  more  swollen,  and  a  little  flushed; 
much  head-ache,  pulse  very  active;  great  thirst;  took  3X.  of 
blood,  much  relieved  by  it;  pulse  softened,  and  diminished  in  fre- 
quency; cold  applications  continued.  Nineteenth,  passed  a  good 
night,  free  from  fever  andpam;  no  return  of  convulsions;  bowels 
rather  tardy;  ordered  senna  tea.  Continued  much  in  this  condi- 
tion until  2Sth,  twelve  days  from  the  first  attack;  this  morning 
was  seized  with  brisk  labour-pains,  and  was  soon  delivered  of  a 
dead  child.  From  the  degree  of  putridity,  it  is  presumable  that 
the  child  died  early  in  or  before  the  attack. 

On  this  case  it  may  be  proper  to  remark:   1st.  That  the  child 

*  I  have  considered  this  as  a  pretty  certain  sign  of  labour  going-  on. 


PUERPERAL  CONVULSIONS.  459 

had  not  been  felt  to  move  for  several  da3-s  before  the  patient  was 
taken  ill — but  this  is  by  no  means  a  certain  proof  of  its  death. 
2d.  Signs  of  labour  were  manifested  on  the  first  day  of  the  illness, 
but  were  evidently  suspended,  or  at  least  not  progressive,  after 
the  second.  I  occasionally  examined  for  several  days,  but  found 
the  OS  tincae  so  rigid,  as  to  preclude  the  idea  of  manual  assistance; 
it  was  therefore  not  attempted.  3d.  Had  manual  aid  been  resort- 
ed to,  I  have  no  hesitation  in  believing  it  would  have  been  ex- 
tremely injurious.  4th.  That  the  convulsions  were  controlled  ten 
days  before  delivery  took  place,  although  from  the  state  of  the 
uterus,  it  was  evident  it  would  sooner  or  later  take  place.  5th. 
That  the  attack  commenced  between  the  seventh  and  eighth 
month  of  pregnancy.  The  lady's  next  pregnancy  was  not  at- 
tended by  this  untoward  accident;  strict  attention  was  paid  to  her 
during  the  whole  period  of  gestation.  She  was  kept  on  a  milk 
and  vegetable  diet — her  bowels  were  kept  open.  She  was  occa- 
sionally blooded,  especially  when  she  complained  of  head-ache — 
she  took,  for  several  months,  three  or  four  doses  daily  of  the 
tincture  of  foxglove,  with,  I  think,  evident  advantage;  and  was 
at  the  proper  time  happily  delivered  of  a  fine  child.  In  her  third 
pregnancy  she  attended  much  less  to  herself,  and  was  not  under 
medical  restraint,  in  consequence  of  which  she  was  again  attack- 
ed by  convulsions,  and  was  held  very  much  as  above  related, 
with  the  exception  that  labour  was  much  more  rapid.  Her  fourth 
pregnancy  was  again  fortunate,  as  she  again  submitted  to  medical 
direction.  Her  fifth  pregnancy  I  have  understood  was  again  un- 
fortunate, and  attended  with  convulsions  like  two  of  the  former — 
I  did  not  see  her  in  this  last  pregnancy,  having  been  absent  in 
the  country  when  it  happened. 

Case  Second. 

Mrs. ,  aged  twenty-six  years,  pregnant  of  her  first  child 

— a  large  plethoric  robust  woman,  was,  on  the  9th  of  September, 
1811,  at  about  five  o'clock,  A.  M.  taken  with  labour-pains,  and 
sent  for  her  midwife;  before  the  midwife  arrived  she  was  seized 
with  terrible  convulsions,  and  1  was  immediately  sent  for — the 
fits  were  frequently  repeated,  and  were  from  their  extreme  vio- 
lence very  threatening — her  face  was  immediately  swelled — her 
eyes  fairly  protruded  from  their  sockets — her  tongue  terribly 
wounded,  &c.     1  instantly  bled  her  from  the  jugu^r  vein  more 


460  PTTERPERAL  CONVULSIONS. 

than  three  pints — examined  her,  and  found  labour  approaching 
— ordered  a  brisk  injection — saw  her  two  hours  after — had  had 
several  severe  fits — pulse  extremely  active — labour  advancing — 
bled  her  twenty  ounces — injection  repeated — a  stream  of  cold 
water  was  poured  on  her  head  during  the  interval  of  the  fits — 
eleven  o'clock,  A.  M.  fits  not  so  severe,  but  pretty  frequent — 
pulse  still  very  active — took  a  quart  of  blood — apparently  much 
relieved — lay  quieter — one  o'clock,  P.  M.  had  had  two  or  three 
fits — very  restless — mourned  every  few  minutes,  desirous  of  get- 
ting from  the  bed — bled  her  ^xii — examined  and  found  the  head 
low  in  the  pelvis,  and  delivered  with  the  forceps — she  had  two  or 
three  fits  after  delivery;  and  remained  insensible  to  everything 
for  forty-eight  hours.  She  now  began  to  show  some  signs  of  re- 
turning sensibility — was  bled  twice  in  the  interval — cold  was 
applied  to  the  head,  and  legs  blistered — she  was  purged  freely 
by  senna  tea.  After  this,  she  gradually  recovered  her  senses. 
She  was  left  completely  blind  for  two  weeks;  she  then  began  to 
see  imperfectly,  but  was  six  weeks  before  she  could  distinctly 
discern  objects.  It  may  not  be  amiss  to  observe,  the  child  was 
living. 

This  case  is  remarkable,  on  account  of  the  severity  of  the  dis- 
ease, and  the  large  quantity  of  blood  that  was  drawn  in  the  short 
period  of  a  few  hours.  She  lost  in  the  first  six  or  seven  hours 
of  her  illness,  one  hundred  and  twenty  ounces  of  blood,  and  about 
one  hundred  and  forty  altogether:  a  quantity  that  might  at  first 
sight  startle  the  timid  or  inexperienced  practitioner;  but  when 
he  reflects  that  here  was  a  patient  labouring  under  one  of  the 
most  ferocious  complaints  in  the  whole  catalogue  of  human  dis- 
eases; the  brain  threatened  with  immediate  destruction;  the  pa- 
tient of  prodigiously  full  habit;  one  who  not  only  neglected  the 
kindly  warning  of  head-ache,  giddiness,  and  occasionally  loss  of 
vision,  by  not  having  recourse  to  bleeding — but,  contrary  to  the 
advice  of  her  midwife,  fed  freely,  and  remained  long  costive — 
what  then  could  avert  the  threatening  consequences  of  this  dis- 
ease, but  the  most  prompt  and  the  most  subduing  remedies?  Had 
not  the  bleeding  been  carried  to  the  extent  it  was,  I  really  believe 
it  would  have  been  unavailing.  Even  as  it  was,  it  did  not  prevent 
temporary  blindness.  Her  second  pregnancy  was  not  attended 
with  any  untoward  circumstance. 


PUERPERAL  CONVULSIONS.  461 


Case  Third. 


Mrs. ,  Nov.  10th,  1797 — pregnant  with  her  second  child, 

and  in  the  eighth  month,  was  seized  while  at  the  ironing-table 
with  vertigo.*  She  fell,  and  was  immediately  attacked  with  con- 
vulsions. T  was  living  near;  and  was  instantly  sent  for — I  found 
her  labouring  under  the  general  symptoms  of  this  disease — I  bled 
her  from  both  arms  at  once,  and  took  from  each  arm  nearly,  if 
not  quite,  a  quart  of  blood.  She  appeared  for  a  short  time  much 
relieved;  that  is,  the  convulsions  were  abated — I  examined  her, 
but  found  no  change  in  the  os  tincse.  An  injection  was  ordered, 
which  operated  well — about  an  hour  after  the  bleeding,  her  pulse 
rose  very  much ;  her  breathing  was  more  laborious  and  sterto- 
rous, and  some  convulsive  twitchings  played  over  the  whole  body. 
She  was  entirely  insensible  to  all  external  impressions — the  pu- 
pils of  the  eye  were  much  dilated;  fearing  a  violent  repetition 
of  the  convulsions,  I  again  tied  up  the  arms,  and  took  about 
twenty-five  ounces  more  of  blood — this  seemed  again  to  moderate 
the  symptoms — no  change  in  the  os  tincse.  Four  o'clock,  P.  M. 
three  hours  after  the  attack,  the  convulsions  were  renewed  with 
considerable  violence — she  was  let  blood  to  the  amount  of  twenty 
ounces — cold  water  was  poured  on  the  head — she  was  again  more 
tranquil,  but  not  less  comatose,  though  the  breathing  was  less 
loud;  she  had  a  copious  black  stool.  Six  o'clock,  P.  M.  had  had 
several  fits,  but  not  as  violent  as  at  first — pulse  still  too  active; 
took  eighteen  or  twenty  ounces  of  blood  from  the  arm — as  the 
pulse  was  now  considerably  reduced,  applied  a  pair  of  blisters  to 
the  legs,  and  sinapisms  to  the  feet.  Ten  o'clock,  no  convulsions 
since  last  visit,  breathing  freer,  but  loud — swallowed  a  little 
water  with  some  difficulty — passed  no  water  since  the  attack; 
introduced  the  catheter,  and  drew  off  a  large  quantity — had  two 
stools — made  an  effort  to  vomit.  Eleventh,  six  o'clock,  A.  M. 
was  called  to  her  suddenly,  as  her  breathing  was  becoming  more 
laborious  and  loud,  and  face  more  flushed,  with  some  convulsive 
agitations;  pulse  rather  too  active;  had  ten  ounces  of  blood  by 
cups,  and  a  large  blister  placed  between  the  shoulders.  From 
this  time  there  was  no  return  of  convulsions.  She  gradually  re- 
covered her  recollection,  but  remained  until  some  time  after  her 

*  She  had  comp>ained.  all  the  morning  of  intense  head-ache,  and  several  times 
said  she  could  not  see — slie  was  advised  to  leave  off  work,  but  would  not. 


462  PUERPERAL  CONVULSIONS. 

delivery,  (which  took  place  at  the  regular  time,  and  with  a  living 
child,)  with  imperfect  vision,  especially  in  one  eye.  She  was, 
for  many  years  after  this,  subject  to  violent  head-aches,  whicli 
were  relieved  constantly  by  bleeding.  She  had  several  children 
after  this  attack,  without  convulsions. 

Case  Fourth. 

Mrs. ,  October  1,  1803,  had  been  in  labour  several  hours; 

she  had  every  appearance  of  being  happily  delivered  of  the  fifth 
child,  when,  during  a  strong  pain,  she  instantly  cried  out,  "  my 
head,  my  head!"  and  immediately  fell  into  convulsions.  She  was 
under  the  care  of  another  physician,  to  whose  aid  I  was  instantly 
called  by  his  own  desire — the  convulsions  were  strong,  and  very 
frequently  repeated — she  was  largely  bled ;  on  examination,  the 
child  was  found  to  be  far  advanced,  and  was  speedily  delivered 
by  the  aid  of  the  forceps — the  convulsions,  however,  continued 
in  spite  of  every  exertion  to  relieve  them,  and  she  died  in  about 
three  or  four  hours  from  the  attack.  Leave  was  obtained  to  open 
the  body;  the  longitudinal  sinus  of  the  dura  mater  contained, 
(by  estimate,)  between  two  and  three  ounces  of  blood;  the  pos- 
terior left  ventricle  was  filled  with  a  bloody  serum — the  other 
ventricles  appeared  sound,  as  did  the  other  parts  of  the  brain — 
no  other  part  was  examined. 

Case  Fifth. 

Mrs. ,  aged  24,  pregnant  for  the  first  time,  was  taken  in 

labour  on  the  10th  March,  1797 — her  labour  proceeded  regularly, 
and  the  child's  head  was  at  the  inferior  strait,  and  every  rational 
expectation  was  entertained  of  a  speedy  delivery,  when  she  sud- 
denlj'  cried  out  with  pain  in  her  head,  and  declared  she  could  see 
no  one  in  the  room;  these  symptoms  had  continued  but  a  few 
minutes,  when  she  was  seized  with  convulsions — she  was  under 
the  care  of  the  late  Dr.  Shippen,  who  requested  that  I  might  be 
sent  for,  and  desired  I  would  bring  my  forceps  with  me.  I  found 
the  patient  in  a  strong  fit,  with  her  face  literally  as  black  as  a 
negro — it  was  agreed  she  should  be  bled  extensively — this  was 
done  from  the  left  jugular  vein,  to  the  amount  of  nearly  two 
quarts;  it  had  an  immediate  eflect  in  tranquillizing  her.  I  now 
examined  her,  and  found  the  head  low  in  the  pelvis;  I  applied 
the  forceps,  and  delivered  her  of  a  dead  child.  Upon  examina- 
tion, it  was  found  there  was  another  child ;  the  uterus  soon  dis- 


PUERPERAL  CONVULSIONS.  463 

covered  a  disposition  to  act;  but  fearing  injury  from  delay,  I 
immediately  delivered  by  the  feet;  which  were  the  presenting 
parts;  the  child  was  healthy  and  did  well:  the  mother  had  no 
return  of  fits,  and  she  rapidly  recovered  the  use  of  her  health,  ex- 
cepting that  of  her  eyesight,  which  did  not  return,  so  as  to  dis- 
cern objects,  for  several  days;  and  her  vision  was  very  feeble 
for  several  weeks. 

Case  Sixth. 

I  was  called  on  the  10th  of  July,   1811,  to  Mrs.  ,  who 

was,  at  the  moment  of  my  arrival,  and  had  been  for  a  consider- 
able time  before,  in  a  strong  convulsive  paroxysm.  I  found  se- 
veral men  diligently  employed  in  holding  her,  and  opposing  her 
motions;  she  was  raised  in  the  middle  like  an  arch,  while  her 
feet  and  head  nearly  met.  She  was  between  seven  and  eight 
months  pregnant  and  subject  to  hysterical  affections. — She  was 
thrown  into  this  by  some  altercation  with  one  of  her  neighbours 
— cold  water  was  dashed  in  her  face,  and  she  was  blooded  to  the 
amount  of  sixteen  ounces.  The  spasms  began  to  give  way  soon 
after,  and  in  the  course  of  about  fifteen  minutes  ceased.  She 
sighed  very  deeply,  and  struck  her  arms  very  forcibly  against 
the  bed,  and  in  a  few  minutes  more,  inquired  what  all  these 
men  were  doing  with  her.  I  gave  her  fifty  drops  of  laudanum, 
and  two  tea-spoonfuls  of  the  tincture  of  assafoetida  in  some  sweet- 
ened water,  and  she  had  no  return  of  the  fit. — She  went  her 
full  time  without  a  repetition  of  them,  and  was  safely  delivered 
of  a  healthy  child. 

I  shall  now  subjoin  two  other  cases,  to  show  of  how  much  con- 
sequence a  proper  distinction  is,  in  the  treatment  of  puerperal 
convulsions. 

Case  Seventh. 

I  was  called  on  the  1 6th  of  April,  1810,  to  Mrs, — ,  said  to 

be  in  strong  convulsions.  I  was  from  home  when  the  messenger 
arrived,  but  went  so  soon  as  it  was  in  my  power.      When  I  went 

into  the  sick  chamber,  I  found  Dr. with  the  patient.     He  told 

me  "  Mrs.  had  been  attacked  about  two  hours   before  with 

convulsions,  and  was  in  the  ninth  month  of  pregnancy — that,  pre- 
viously to  the  attack  of  the  fits,  she  had  complained  of  violent  pain 
in  the  forehead,  which  she  told  her  husband  she  could  cover  with 
her  finger.  She  had  this  pain  several  days,  but  it  was  much  more 


464  PUERPERAL  CONVULSIONS. 

iniense  this  morning,  and  was  attended  with  a  sensation,  as  if  a 
piece  of  hlack  gauze  was  before  her  face.  She  was  stooping  for 
some  time  over  a  trunk,  in  which  ?he  was  arranging  some  articles, 
when  she  was  seized  and  fell  on  the  floor  in  strong  convulsions," 
She  was  now  lying  senseless  and  v^^ithout  motion  on  the  bed; 
she  breathed  very  lieavily,  and  snored  loudly — her  face  much 
swoln  and  of  a  purple  hue — the  pulse  frequent  and  small,  and  the 
extremities  cold.  I  inquired  what  had  been  done,  and  was  in- 
formed by  Dr.  he  had  given  her,  twice,  sixty  drops  of  laud- 
anum at  a  time,  and  that  since  the  last  dose  she  had  had  no  fit,  and 
was,  in  his  opinion,  very  much  better,  requiring  nothing  but  sleep 
to  restore  her. — I  told  him  very  plainly,  that  I  thought  he  had 
mistaken  the  patient's  case,  and  had,  in  my  opinion,  sealed  her 
fate  by  the  use  of  the  laudanum, — He  appeared  alarmed,  but  not 
altogether  convinced, — We  did  everything  that  we  thought  might 
be  useful  J  but  all  exertion  was  unavailing,  and  the  patient  died  in 
about  three  hours. — I  could  not  procure  leave  to  open  the  body. 


About  three  months  after  the  above  event  had  taken  place,  viz. 
on  the  20th  of  July,  1810,  the  same  gentleman  was  called  to  Mrs. 

,  labouring  under  convulsions.     I  was  sent  for  at  his  request. 

Before  I  arrived,  he  had  bled  the  patient  very  freely,  (40  ounces,) 
by  which  she  was  considerably  relieved — she  was  near  her  full 
time  of  gestation.  From  her  peculiar  motions  and  breathing,  I 
suspected  labour  had  commenced — she  was  examined,  and  the  os 
uteri  was  dilated  to  about  the  size  of  a  dollar.  It  was,  however, 
pretty  rigid.  The  convulsions  returned  with  considerable  force; 
the  patient  was  again  bled  about  thirty  ounces;  a  stimulating  in- 
jection was  thrown  up  the  rectum,  which  operated  freely;  the 
mouth  of  the  uterus  was  now  well  dilated ;  I  turned,  and  delivered 

a  living  child.     Mrs.  had  one  fit  after  delivery,  but  it  was 

not  severe.  She  recovered  her  senses  and  feelings  on  the  second 
day  after  delivery,  and  no  other  inconvenience  was  experienced, 
except  some  dimness  of  sight,  and  slight  head-ache.  Several 
days  before  the  attack  of  convulsions,  she  had  complained  of  the 
head-ache,  and  that  particular  sensation  of  a  nail  being  driven 
into  the  head,  and  also  an  occasional  loss  of  sight. 

The  two  cases  just  related,  form  a  happy  contrast  in  the  mode 
of  treatment;  the  first  case  proving  so  unfortunate,  made  a  strong 


INVERSION  OF  THE  UTERUS.  465 

impression  on  the  mind  of  Dr.  ,  who  very  properly  profited 

by  it  in  the  second  case.  He  candidly  confessed  they  were  as  si- 
milar as  any  two  cases  of  disease  could  be,  and  declared  himself 
much  shocked  at  the  reflections  which  the  unfortunate  case  gave 
rise  to. 

In  every  case  of  convulsions,  it  is  but  too  common  for  bystand- 
ers to  oppose,  by  strength,  the  contractions  of  the  agitated  muscles. 
This  practice  cannot  be  too  severely  reprehended;  for  it  is  both 
injurious  and  unnecessary;  it  subjects  the  patient  to  severe  mus- 
cular pains,  which  last  for  very  many  days  after  the  fits  subside. 
All  that  should  be  done  in  such  cases  is,  to  prevent  the  patient 
doing  herself  mischief,  or  to  prevent  her  from  throwing  herself 
from  the  bed;  and  as  a  very  moderate  exertion  is  sufficient  for 
this  purpose,  therefore,  violence  should  never  be  employed. 


CHAPTER  XXXIV. 

ON  THE  INVERSION  OF  THE  UTERUS. 

1265.  This  untoward,  and  too  fatal  accident,  is,  perhaps,  more 
frequent  than  is  commonly  supposed.  Instances  of  sudden  death 
after  delivery  often  remain  unaccounted  for;*  and  there  is  every 
reason  to  believe,  that  this  displacement  of  the  uterus  is  sometimes 
the  cause.  Examinations  of  women  who  have  died  during  labour, 
or  soon  after  delivery,  are  not  so  frequent  as  their  importance 
seems  to  demand.  This  indifference  to  examinations  after  death, 
arises,  first,  from  an  adequate  estimate  of  their  value,  even  by 

•  Levret  in  his  chapter,  "  sur  la  cause  la  plus  ordinaire,  de  la  mort  subite,  &c. 
tres  peu  de  temps  a]n-es  I'accouchement,"  attributes  the  greater  part  of  such 
deaths  to  the  want  of  contractile  power  in  the  uterus,  thereby  giving  rise  to  fa- 
tal haemorrhages.  He  does  not  appear  to  have  been  aware,  that  the  partial  in- 
version may  be  a  cause  of  death,  or  in  some  instances  contribute  to  it,  as  he 
passes  without  notice  this  cu'cumstance  in  the  case  he  quotes  from  Mauriceau; 
who  says,  on  opening  the  body,  "  nous  trouvames  le  fond  de  la  rtiatrice  un  peu 
deprime  enbedans,  comme  est  le  cul  d'une  fiolle  de  verre,  au  lieu  d'avoir  une 
figure  rond,  comme  on  le  voit  ordinairement."  Obs.  230.  Wliile  Ant.  Petit 
thought  the  "inversion  of  the  uterus  to  be  impossible;"  and  declared  that  those 
authors  who  mention  tliis  condition  of  tlie  uterus,  had  mistaken  a  polypus  at- 
tended by  a  i)rolapbus  of  tlie  vagina  for  it. 
i9 


466  INVERSION  OF  THE  UTERUS. 

medical  practitioners;  second,  from  the  aversion  most  people  feel 
to  have  their  friends'  remains  disturbed;  third,  to  the  disingenuous 
conduct  of  the  attending  physician  himself^  who  may  not  wish  the 
cause  of  death  to  be  ascertained,  lest  it  should  do  injury  to  his 
character,  either  from  his  not  having  known  or  suspected  the  true 
one,  or  by  exposing  some  lesion  for  which  he  fears  the  world 
would  hold  him  accountable,  though  he  had  no  agency,  either  di- 
rectly or  indirectly,  in  producing  the  accident  by  which  death  has 
been  produced.  Hence,  as  I  have  just  observed,  this  complaint  is, 
most  probably,  every  now  and  then  concealed;  and  therefore, 
the  frequency  of  the  inversion  of  the  uterus  in  producing  death, 
cannot  be  exactly  estimated. 

1266.  Inversions  of  the  uterus  may  be  either  complete,  or  in- 
complete— by  a  complete  inversion,  I  mean  the  passing  of  the  fun- 
dus and  body  of  the  uterus  through  the  os  externum,  or  being  turn- 
ed entirely  inside  out,  to  the  very  mouth  of  this  organ;  when  this 
takes  place  the  mouth  of  the  uterus  is  looking  upwards,  and  is 
within  the  cavity  of  the  abdomen.  But  it  is  not  necessary  to  the 
complete  inversion,  that  the  body  and  fundus  escape  through  the 
OS  externum;  as  this  condition  may  happen,  and  yet  the  uterus 
be  concealed  within  the  vagina. 

1267.  Mr.  Burns  says,  when  the  inversion  is  complete,  the  fun- 
dus is  "  protruded  out  of  the  vagina."  This  is  not  essential  to  the 
definition;  since,  I  have  known  the  uterine  tumour  to  pass  through 
the  OS  externum,  without  entirely  inverting  the  neck  to  the  mouth; 
and  again,  I  have  known  the  inversion  to  be  complete,  and  the 
fundus  not  escape  from  the  vagina. 

1268.  The  incomplete,  is  where  neither  the  body  nor  fundus 
have  entirely  escaped  through  the  os  uteri,  and  may  be  in  differ- 
ent degrees;  first,  the  simple  depression,  or  where  the  fundus  falls 
down  to  the  mouth  of  the  uterus;  but  is  prevented  from  passing 
through  it,  by  the  latter  being  contracted;  or  the  force  may  have 
been  insufiicient  for  thisjpurpose;  second,  where  it  has  passed 
perhaps  half  its  length  through  the  os  uteri;  third,  where  it  is  com- 
pletely inverted,  with  the  exception  of  a  portion  of  the  body  and 
neck.  In  the  two  latter  conditions,  the  body  and  fundus  may  be 
compressed  or  strangulated,  by  the  neck  of  the  uterus  contracting 
forcibly  upon  the  protruded  part;  or  it  may  be  free  from  this  re- 
straint; each  of  these  presents  different  indications. 

1269.  Proximate  cause. — For  the  uterus  to  become  completely 
inverted,  several  circumstances  must  combine;  first,  the  fundus 


INVERSION  OP  THE  UTERUS.  467 

must  most  probably  contract,  while  the  body  and  neck  must  be 
flaccid ;  second,  a  force  or  weight  must  be  applied  to  the  fundus, 
which  is  capable  of  making  it  descend  through  the  os  internum: 
this  force  may  be  a  power  applied  to  the  cord;  and  the  weight 
may  be  the  placenta  itself,  when  it  is  engrafted  immediately  upon 
the  fundus,  or  the  pressure  of  some  of  the  abdominal  viscera,  &c. 
But  let  it  be  remembered  that,  in  the  incomplete,  the  mouth  of 
the  uterus  looks  downwards,  or  into  the  vagina,  and  is  always 
within  the  vaginal  ■portion  of  the  jjelvis,  though  completely 
filled  hy  the  descending  jioy^tion  of  the  body  of  the  uterus.  See 
par.  1266.  See  Plates  XIV.,  XV.,  XVI.,  XVII. 

1270.  Remote  cause. — The  remote  cause  of  this  accident,  is 
the  want  of  power  or  disposition,  in  the  body  and  neck  of  the 
uterus,  to  contract.  This  may  be  occasioned  by  an  over-disten- 
tion  of  this  organ,  from  an  excess  of  liquor  amnii;  from  the  unu- 
sual size  of  the  foetus;  from  a  compound  pregnancy;  from  hsemor- 
rhagy;  from  passions  or  emotions  of  the  mind ;  from  exhaustion, 
in  consequence  of  previous  disease;  from  long-continued  uterine 
efforts  to  effect  delivery,  &c. 

1271.  Symptoms. — When  this  accident  takes  place,  the  woman 
almost  instantly  complains  of  a  severe  and  distressing  pain  about 
the  region  of  the  uterus ;  an  effort  to  force  or  bear  down;  nausea, 
and  sometimes  vomiting;  great  faintness,  with  more  or  less  hae- 
morrhage; cold  clammy  sweats;  pulse  small,  frequent,  or  ex- 
tinct. A  variety  of  nervous  symptoms  may  also  occur  of  a  most 
distressing  kind,  arising  most  probably  from  the  new  situation  tlie 
abdominal  viscera  are  forced  to  take,  when  deprived  of  the  sup- 
port of  the  uterus. 

1272.  If  we  examine  per  vaginam,  it  will  be  found  that  the 
vagina  is  occupied  by  a  firm  resisting  tumour,  covered  by  the 
placenta,  or  otherwise,  as  the  period  may  be  at  which  this  acci- 
dent occurs;  or  the  fundus  and  body  may  be  pushed  through  the 
OS  externum,  either  bare,  or  covered  by  the  placenta.  This  ca- 
sualty may  take  place  immediately  after  the  birth  of  the  child; 
or  it  may  not  occur  for  hours,  or  even  days,  after  this  event.*  If 

*  A  very  remarkable  case  of  "complete  inversion"  taking  place  a  long  time 
subsequently  to  labour,  is  given  with  great  clearness  and  accuracy,  by  Mr. 
Watkinson,  in  Med.  and  Phys.  Jour.  Vol.  VII.  p.  433.  This  case  was  of  long 
duration,  and  eventually  and  suddenly  fatal,  after  it  had  been  amputated  by 
cuttirig  through  the  prolapsed  and  inverted  vagina.  Mr.  AV.  assigns,  as  the 
cause  of  death,  the  relaxed  state  of  the  os  uterij  and  perhaps  of  the  uterus  it- 


468  INVERSION  OF  THE  UTERUP. 

the  hand  be  now  placed  upon  the  abdomen,  we  shall  fail  to  find 
the  uterus, 

1273.  Incomplete. — The  incomplete  must  have  the  same  ge- 
neral causes  as  regards  the  effect  upon  the  fundus  and  body — 
that  is,  the  fundus  cannot  be  supported  by  the  body,  from  its  loss 
of  power,  by  the  operation  of  either  of  the  same  remote  causes, 
(1270)  but  is  prevented  from  entirely  passing  through  the  neck, 
by  the  latter  contracting,  and  arresting  it  within,  or  only  permit- 
ing  it  to  pass  in  part.  The  same  general  train  of  symptoms  oc- 
cur, but  this  condition  is  almost  always  attended  with  a  greater 
discharge  of  blood,  than  when  the  inversion  is  complete.*  If  an 
examination  be  carefully  made  per  vaginam,  the  fundus  of  the 
uterus  may  be  detected  in  one  of  the  situations  mentioned  for 
this  species  or  variety  of  inversion,  (1268.) 

1274.  The  incomplete  inversion,  we  have  observed,  has  va- 
rious degrees  of  derangement;  namely,  from  the  simple  depres- 
sion, (1268)  to  the  entire  escape  of  the  inverted  body  of  the  ute- 
rus; but  they  are  not  equally  distressing  or  dangerous,  though 
neither  condition  is  free  from  risk.  Thus  the  simple  depression, 
is  not  necessarily  as  fatal  as  when  the  fundus  alone  has  passed 
through  the  os  uteri;  and  the  latter  not  so  full  of  danger,  as  when 
the  inversion  more  nearly  approaches  to  being  complete.  Per- 
haps mere  depression,  unaccompanied  by  haemorrhage,  might 
not  be  absolutely  fatal;  but  as  there  can  be  no  possible  security 
against  this  condition,  longer  than  the  placenta  preserves  its  en- 
tire connection  with  the  uterus,  it  must  be  regarded  as  a  case  of 
possible,  nay  of  probable  danger;  and  consequently,  should  never 
be  trusted  after  it  is  detected, 

1275.  The  symptoms,  however,  in  each  of  these  degrees  of  in- 
version, differ  only  in  intensity;  for  all  are  marked  by  a  peculiar- 
ity of  suffering,  the  force  of  which,  will  very  much  depend,  upon 
the  extent  of  the  displacement  of  the  fundus  and  body  of  the  ute- 

self,  occasioned  by  the  long-proti-acted  hasmorrhage,  and  the  formation  of  co- 
agula;  in  expelling  the  latter,  the  uterus  was  perhaps  inverted. 

*  It  is  a  remarkable  fact,  that  less  blood  is  lost  when  the  uterus  is  completely 
than  when  it  is  partially,  inverted.  This  is  not,  perhaps,  of  difficult  explana- 
tion; since,  when  the  inversion  is  complete,  the  uterus  contracts  to  a  certain 
extent;  and  by  this  contraction,  the  now  internal  surface  of  this  organ  is  made 
to  impigne  upon  the  vessels  which  carry  blood  to  it,  and  thuslnterrupts  or  cuts 
off'  fresh  supplies  of  this  fluid.  It  may  also  be  proper  to  observe,  that  haemor- 
rhage is  never  so  suddenly  alarming,  in  cases  of  inversion,  as  it  is  when  it  arises 
from  the  uterus  being  in  a  state  of  atony,  and  the  placenta  detached  from  it. 


INVERSION  OP  THE  UTERUS,  469 

rus,  and  the  constricting  force  of  the  os  uteri  through  which  they 
may  have  passed.  For  instance;  the  simple  depression  will  be 
marked  by  less  suffering,  than  when  the  fundus  has  passed  the 
mouth  of  the  uterus;  and  the  alarming  symptoms  in  the  last  case, 
will  be  in  proportion  to  the  contraction  of  the  os  uteri;  if  this  be 
feeble,  the  risk,  and  sufferings,  will  be  comparatively  moderate; 
but  when  the  stricture  is  very  severe  they  are  not  only  of  the  most 
distressing  kind,  but  highly  dangerous.  Yet  each  of  these  con- 
ditions may  accidentally  be  equally  dangerous,  though  not  equally 
alarming  in  the  intensity  of  their  symptoms.  Thus,  the  simple 
depression,  may  be  as  fatal  as  a  more  extensive  displacement, 
in  consequence  of  the  profuseness  of  the  flooding  which  may 
attend  it,  though  the  sufferings  of  the  patient  may  be  much  less 
severe  than  when  the  inversion  is  more  extensive.     (See  Case  I.) 

1276.  The  mechanism  of  inversion  is  sufficiently  simple;  it 
seems  to  require  but  a  state  of  atony  of  the  uterus  to  produce  it, 
with,  (perhaps,)  more  or  less  pressure  upon  the  fundus  of  this 
organ;  or,  possibly,  the  mere  contraction  of  the  fundus,  and  the 
implantation  of  the  placenta  on  this  part.  When  this  derange- 
ment takes  place  before  the  delivery  of  the  after-birth,  we  have 
much  reason  to  suspect  that  its  weight,  as  well  as  its  location, 
materially  contribute  to  its  production — this  location  of  the 
placenta,  indeed,  seems  to  be  almost  a  sine-qua-non  to  inversion; 
for  we  either  find  the  placenta  discharged  from  the  vagina,  or 
else  attached  to  the  fundus  of  this  organ;  now,  had  the  placenta 
been  attached  to  any  portion  of  the  body  of  the  uterus,  that  part 
must  have  contracted  that  it  might  be  thrown  off;  and  that  con- 
traction of  the  body  of  the  uterus,  most  probably  would  have 
given  such  support  to  the  fundus  as  to  have  prevented  its  falling 
down. 

1277.  It  is  almost  universally  believed,  that  an  undue  force 
applied  to  the  cord  for  the  delivery  of  the  placenta,  is  the  princi- 
pal cause  of  this  accident;  but  in  this  I  differ  from  such  as  have 
adopted  this  opinion ;  and  for  the  following  reasons:  first,  because 
the  accident  has  occurred  after  the  delivery  of  the  placenta;  se- 
cond, because  it  has  taken  place,  when  no  such  force  has  been 
applied.*     But  the  caution,  not  to  apply  much  force  to  the  cord 

*  In  evidence  of  this,  Mr.  Welsh  says  in  his  account  of  a  case  of  inversion, 
that,  "  on  dividing-  the  funis  to  remove  the  child,  I  was  extremely  surprised  to 


470  INVERSION  OF  THE  UTERUS. 

to  deliver  the  placenta  is  founded  upon  just  and  important  prin- 
ciples; since,  did  the  disposition  to  inversion  exist,  and  this  mass 
be  attached  to  the  fundus,  it  would  be  almost  certain  to  produce 
it;  whereas,  perhaps,  without  such  force,  the  woman  might  escape 
from  the  danger. 

1278.  Mr.  Burns,  after  enumerating  several  causes  of  inver- 
sion, such  as  pulling  of  the  cord;  the  too  sudden  delivery  of  the 
child  when  the  cord  is  too  short,  &c.  says, "  from  the  same  cause, 
or  sometimes  perhaps  from  sudden  pressure  of  part  of  the  intes- 
tines on  the  fundus  uteri,  occasioned  by  strong  contraction  of 
the  abdominal  muscles,  a  part  of  the  fundus  becomes  depressed 
like  a  cup,  and  encroaches  on  the  uterine  cavity.  -  This  generally 
rectifies  itself  if  let  alone."  I  would  inquire,  for  the  sake  of  in- 
formation, how  this  dipping  of  the  fundus  is  known  to  exist?  and 
how  it  is  ascertained,  that  it  "  generally  rectifies  itself  if  let 
alone?" 

1279.  I  can  readily  comprehend,  that  an  unusually  short  cord, 
with  the  sudden  expulsion  of  the  child,  may  produce  inversion, 
even  when  there  is  no  disposition  to  atony  in  the  uterus;  as  the 
fundus  may  be  dragged  down  at  the  instant  relaxation  is  about  to 
take  place;  but  I  confess  myself  entirely  at  a  loss  to  comprehend 
what  Dr.  Merriman*  may  mean  by  a  short  cord,  when  its  length 
permitted  a  child,  by  a  sudden  effort  of  the  uterus,  to  be  "thrown 
to  the  extremity  of  the  bed,"  though  this  cord  was  "  naturally 
short,  besides  being  twice  passed  round  the  child's  neck,"  and  the 
placenta  retained,  "  though  low  in  the  pelvis."  Quere,  if  this  be 
a  short  cord,  what  constitutes  a  long  one? 

1280.  The  indications  in  inversion  are  simply  these;  first,  to 
restore  the  prolapsed  fundus  when  practicable;  second,  to  pre- 
vent a  reinversion  after  restoration;  and  third,  if  the  fundus  can- 
not be  restored,  to  prevent  death  by  taking  off"  the  constriction  oc- 
casioned by  the  contraction  of  the  mouth  of  the  uterus. 

1281.  When  the  fundus  is  prolapsed  to  the  mouth  of  the  uterus 
but  contained  within  it,  should  the  mouth  of  the  uterus  be  suffi- 
ciently yielding,  the  hand  must  be  gradually  passed  through  it, 
and  the  fundus  carried  upward  until  restored — if  the  placenta 
has  been  thrown  off",  we  need  but  retain  the  hand  within  the  ute- 

findthe  uteru3  completely  inverted,  and  lying  without  tlie  labia,  on  tlie  thigh. ' 
— Load.  Med.  andPhys.  Journal.  Vol.  F!  p.  451. 
*  Dcuman's  Midwifery,  Francis's  ed.  p.  514. 


INVERSION  OP  THE  UTERUS.  471 

rine  cavity,  until  we  have  sufficient  evidence  of  its  disposition  to 
contract,  and  to  maintain  that  contraction.  If  the  placenta  has  not 
been  thrown  off,  it  will  be  found  either  loose  or  adherent — if  loose, 
it  must  be  withdrawn  with  the  hand,  after  we  are  satisfied  that 
we  may  trust  the  uterus  to  itself.  If  adherent,  we  must  gently 
separate  it  after  the  uterus  shows  signs  of  returning  power,  and 
wdien  separated,  it  must  be  taken  from  the  uterus,  when  the  hand 
is  retracted.  It  is  more  than  possible  that  the  mouth  of  the  ute- 
rus may  contract  so  firmly  in  this  species  of  inversion,  as  to  pre- 
vent the  introduction  of  the  hand  to  restore  it.  In  this  case,  shall 
we  act  upon  the  hope  that  this  case  "generally  rectifies  itself  if 
let  alone,"  or  shall  we  attempt  the  restoration  of  the  fundus  by 
some  safe  mechanical  contrivance?  Might  not  a  stiff  piece  of 
whalebone,  or  tough  wood,  armed  by  a  piece  of  rag,  be  employed 
with  a  prospect  of  success?  for  we  must  ever  deprecate  violence 
to  the  mouth  of  the  uterus. 

1282.  Should  the  fundus  have  escaped  in  part  through  the 
mouth  of  the  uterus,  it  should  be  as  quickly  as  possible  returned, 
by  pressing  the  most  depending  and  central  portion  of  the  tumour, 
gently,  steadily,  and  perseveringly  in  the  direction  of  the  axis  of 
the  OS  uteri  until  it  retire;  then  if  it  do  not  return  to  its  proper 
situation  by  its  own  resiliency,  we  must  pursue  it  with  the  \\^j^d. 
through  the  mouth  of  the  uterus,  nor  should  it  be  left  unsupported 
until  placed  in  situ.  And  the  hand  must  be  kept  in  the  uterus, 
until,  by  the  contraction  of  the  uterus,  there  is  assurance  it  may 
be  withdrawn  with  safety. 

1283,  We  now  and  then  meet  with  cases,  in  which  therelaters 
would  seem  to  persuade  us  that  some  especial  providence  had  in- 
terfered to  save  their  patients,  since  they  record  departures  in  the 
animal  economy  that  can  be  accounted  for  upon  no  other  principle. 
Now,  nothing  is  more  to  be  dreaded  than  the  atony  of  the  uterus 
after  delivery;  we  have  already  declared  it  to  be,  (1270)  one  of 
the  remote  causes  of  the  "inversion  of  the  uterus;"  and  every 
body  acknowledges  it  to  be  the  reason  why  haemorrhage  takes 
place  after  delivery,  when  the  placenta  is  separated,  either  par- 
tially or  altogether.  Yet  we  find  mention  of  a  case  of  inversion 
by  Dr.  Loftier,  in  which  the  fundus  of  the  uterus  could  not  be  re- 
tained after  reposition,  owing  to  the  loss  of  the  tonic  power  of  this 
organ,  but  again  and  again  descended  through  the  os  uteri.— 
"  The  fundus  uteri  having  receded  through  the  orifice  of  the  uterus, 

■  I  pursued  it  with  my  hand,  which  I  kept  in  the  uterus,  waiting  for 


472  INVERSION  OP  THE  UTERUS. 

the  contraction  of  this  organ.  But  after  I  had  continued  in  this 
position  about  half  an  hour  without  perceiving  any  contraction,  I 
was  obHged  to  withdraw  my  hand,  when  the  fundus  immediately 
descended,  but  was  prevented  passing  through  the  orifice."  A 
variety  of  things  were  done  for  twelve  hours  to  promote  the  con- 
traction of  the  uterus,  as  stimulating  injections  into  its  cavity, 
frictions,  &c.  but  all  to  no  purpose;  for  the  uterus  remained  in 
the  same  flaccid  state,  and  he  was  at  last  under  the  necessity  of 
propping  up  the  fundus  by  a  tube  made  of  horn.  This  was  ef- 
fected without  much  difficulty;  the  lochia  passed  off  properly, 
&c.  and  the  woman  recovered.  Now  this  case  is  altogether  a 
miracle! — a  woman  had  an  uncontracted  uterus;  a  separated 
placenta;  and  yet  there  was  no  haemorrhage!!! — at  least  no 
mention  is  made  of  any,  though  the  uterus  remained  days  uncon- 
tracted. * 

1284.  If  the  placenta  offer  itself  before  the  prolapsed  fundus, 
we  may,  if  detached,  deliver  it  immediately;  but  if  it  be  adherent, 
and  the  mouth  of  the  uterus  does  not  offer  too  much  resistance, 
it  must  be  carried  up  with  the  fundus,  and  separated,  as  before 
directed,  (1281).  Should  we,  however,  find  much  opposition  to 
reduction,  and  this  evidently,  in  part,  arising  from  the  bulk  of  the 
mass  to  be  restored,  it  will,  (perhaps,  )t  be  best  to  separate  it  care- 
fully, and  then  carry  up  the  fundus. 

1285.  Should  the  inversion  be  complete,  it  will,  for  the  most 
part  be  impossible  to  restore  it,  J  especially  if  several  hours  should 
have  elapsed  after  the  accident.  Dr.  Denman  says,  "  the  impos- 
sibility of  replacing  it,  if  not  done  soon  after  the  accident,  has 
been  proved  in  several  instances,  to  which  I  have  been  called, 
so  early  as  within  four  hours,  and  the  difficulty  will  be  increased 
at  the  expiration  of  a  longer  time.  Whenever  an  opinion  is  ask- 
ed, or  assistance  required,  in  those  cases  which  may  not  impro- 
perly be  called  chronic  inversions,  it  is  almost  of  course  that  the 

*  Med.  and  Phys.  Journ.  Vol.  n.  p.  207, 

■\  I  say  "perhaps,"  because  I  cannot  speak  more  positively  upon  a  subject 
on  which  my  experience  is  so  limited.  The  propriety  of  this  practice  I  wish  to 
leave  to  farther  observation,  for  having  met  with  but  four  cases  of  "  inversion,"^ 
I  think  that  number  inadequate  to  establish  the  best  mode  of  practice. 

t  I  would  not  dare  to  say,  it  would  be  impossible  to  restore  tlie  uterus  after 
its  complete  inversion;  though  I  beUeve  it,  at  tliis  moment. 

§  Since  ike  above  period  J  kuue  been  several  more  cciaei  of  inversion.  Sec  note  lo 
par,  1301. 


INVERSION  OP  THE  UTERUS.  473 

reposition  should  be  attempted ;  but  I  have  never  succeeded  in 
any  one  instance,  though  the  trials  were  made  with  all  the  force 
I  dare  exert,  and  with  whatever  skill  and  ingenuity  I  possessed  ; 
and  I  remembered  the  same  complaint  being  made  b)'^  the  late  doc- 
tors Hunter  and  Ford  ;  so  that  a  reposition  of  a  uterus  which  has 
been  long  inverted,  may  be  concluded  to  be  impossible.  It  seems 
as  if  the  cervix  of  the  uterus  continued  to  act,  or  had  soon  acted 
in  such  a  manner,  as  to  gird  the  inverted  uterus  so  firmly,  that  it 
could  not  be  moved."  This  account  of  the  impracticability  of 
restoring  the  fundus  when  the  inversion  is  complete,  is  in  strict 
conformity  with  my  own  experience. 

1286.  It  is  true,  it  is  said,  that  the  uterus  has  been  reinstated 
after  "complete  inversion  ;"  but  of  this  we  may  justly  entertain 
doubts  ;  for  the  one  recorded  by  Mr.  White,  purporting  to  be  of 
this  kind,  was  certainly  not  one  of ''complete  inversion."  In  Mr. 
White's  patient,  we  recognize  nothing  more  than  a  partial  one, 
as  the  symptoms  declare.  Mr.  W.  says  he  saw  the  patient  about 
an  hour  after  the  accident,  and  "found  the  uterus  of  the  size  of  a 
large  new-born  infant's  head,  totally  inverted.''^  Yet  he  declares 
the  woman  "  was  in  great  pain,  and  had  lost  much  blood ;"  neither 
of  which  circumstances  attends  complete  inversion  ;  for  it  seems 
to  be  agreed,  that  there  is  not  much  haemorrhage  at  this  time, 
and  I  know  that  pain  immediately  ceases  when  it  becomes  com- 
plete, as  I  shall  state  presently. 

1287.  This  patient  "was  very  faint,  and  no  pulse  could  be  felt 
in  either  arm  :"  a  condition  which  constantly  attends  the  partial 
inversion  ;  especially,  when  the  mouth  of  the  uterus  contracts 
firmly  upon  the  body,  producing  a  strangulation  of  the  uterus  : 
which  was  precisely  the  situation  of  Mr.  W.'s  patient ;  for  he  de- 
clares "  the  neck  was  a  little  contracted."  Now,  it  must  be  obvi- 
ous upon  a  moment's  reflection,  that,  if  the  inversion  were  com- 
plete, the  mouth  of  the  uterus  cannot  be  felt ;  for  this  part  now 
offers  its  opening  to  the  cavity  of  the  abdomen,  and  is  not  tangible 
by  the  finger.     See  case  second,  and  Plate  XVI. 

1288.  There  is  a  condition  of  the  partial  inversion,  where  it  is 
as  certainly  impossible  to  restore  the  fundus,  as  if  the  inversion 
were  complete ;  and  this  is,  where  the  fundus  and  a  part  of  the 
body  have  passed  the  os  uteri,  and  the  latter  contracts,  "  so  as," 
as  Dr.  Denman  expresses  it,  "to  gird  the  inverted  uterus  firmly, 
so  that  it  cannot  be  moved. '^  When  this  happens,  the  stricture 
occasioned  by  the  contracted  mouth,  is  so  firm  and  resisting,  that 

60 


474  INVERSION  OF  THE  UTERUS. 

a  finger  cannot  be  passed  between  its  edge  and  the  confined  ute- 
rus— in  this  case,  I  believe  it  to  be  impossible  to  pass  the  fundus,  as 
the  constriction  would  not  yield  to  any  force  we  could  use  with 
safety. 

1289.  This  variet}^  of  partial  inversion,  produces  the  most  ter- 
rible and  alarming  symptoms  imaginable;  pain,  faintness,  vomit- 
ing, delirium,  cold  sweats,  extinct  pulse,  convulsions,  and,  if  not 
speedily  relieved,  death.  Under  such  sufferings,  when  all  hope 
of  restoration  is  at  an  end,  I  have  advised,  with  a  view  to  termi- 
nate them,  and  to  preserve  life,  that  the  fundus  and  body  should 
be  drawn  still  farther  down,  so  as  to  complete  the  inversion. 
Should  the  placenta  be  attached,  it  must  be  carefully  separated 
before  we  draw  down  the  fundus. 

1290.  The  propriety  and  safety  of  this  plan,  are,  it  must  be  con- 
fessed, predicated  upon  the  happy  result  of  a  solitary  case;  but, 
from  its  entire  and  speedy  success  in  this  instance,  it  is  rendered 
inore  than  probable  that  it  will  be  of  equal  advantage,  if  employ- 
ed in  others.  "  All  reasoning  upon  the  subject,"  is  certainly  in  its 
favour;  and  experience,  so  far  as  a  single  case  may  be  entitled 
such,  is  equally  so.      See  note  to  par.  1301. 

1291.  Should  the  practitioner,  however,  be  so  fortunate  as  to 
meet  with  a  case  where  the  mouth  does  not  confine  the  protruded 
part,  he  should  attempt  restoration,  however  large  a  portion  of  the 
uterus  may  have  passed  through  the  os  uteri,  by  gentl)?-,  but  firm- 
ly compressing  it,  so  as  to  reduce  its  size;  having  first  removed 
the  placenta,  if  not  previously  done,  and  urging  the  prolapsed  part 
upward  in  the  axis  of  the  os  uteri.  In  such  a  case,  perseverance 
may,  I  am  willing  to  admit,  do  much,  and  it  ought  most  certainly 
to  be  tried  if  there  be  the  smallest  chance  of  success. 

1292.  The  chance,  however,  should  be  clearly  ascertained,  by 
carefull}^  examining  the  condition  of  the  constricting  part — if  it 
be  soft  and  yielding,  a  hope  may  be  indulged  that  the  resistance 
may,  by  proper  proceeding,  be  overcome.  If  this  friendly  condi- 
tion obtain,  there  will  be,  beside  this  pliant  disposition  of  the  os 
uteri,  an  absence  from  all,  or  nearly  all  the  terrible  symptoms  just 
enumerated  (1289);  but,  if  he  cannot  find  the  mouth  of  the  uterus 
by  a  careful  examination  after  the  placenta  is  removed,  and  if 
there  should  be  an  absence  of  the  train  of  appalling  symptoms 
above  named,  he  should  desist  at  once  from  every  attempt  at  re- 
duction, as  his  efforts  will  not  be  attended  by  success;  and  the  con- 


INVERSION  OP  THE  UTERUS.  475 

tinuance  of  them  will  not  only  give  his  unhappy  patient  niuch 
unnecessary  pain,  but  will  hasten  her  death. 

1293.  The  mode  to  be  pursued,  when  it  is  necessary  to  com- 
plete the  inversion,  is  simply  to  place  the  woman  upon  her  back 
near  the  edge  of  the  bed;  and  have  her  legs  supported  by  proper 
assistants — the  hand  is  to  be  introduced  along  the  inferior  part  of 
the  vagina,  but  sufficiently  high  to  seize  the  uterus  pretty  firmly; 
it  is  then  to  be  drawn  gently  and  steadily  downward  and  outward, 
until  the  inversion  is  completed;  this  will  be  known  by  a  kind  of 
jerk  announcing  the  passing  of  the  confined  part  through  the 
stricture.  Traction  should  now  cease,  and  the  part  be  carefully 
examined;  if  the  inversion  be  complete,  the  mouth  of  the  uterus 
will  no  longer  be  felt,  and  there  will  be  an  immediate  cessation 
of  pain,  and  other  distressing  sensations. 

1294.  The  proposal  just  made,  "to  convert  an  incomplete  in- 
version into  a  complete  one,"  in  cases  in  which  it  is  deemed  im- 
possible to  place  the  fundus  in  situ,  is  either  an  important  im- 
provement in  the  treatment  of  this  complaint,  or  is  a  most  mis- 
chievous direction:  it  therefore  not  only  merits,  but  absolutely 
requires  a  dispassionate,  and  candid  examination.  In  inquiring 
into  the  merits  of  this  case,  I  shall  lay  aside  every  feeling  of  self- 
love  that  might  reasonably  be  supposed  I  would  cherish,  as  the 
author  of  an  original,  and  perhaps  a  highly  important  suggestion; 
and  I  will,  also,  as  far  as  either  my  experience,  or  my  reading 
shall  enable  me,  give  the  subject  a  temperate,  and  liberal  con- 
sideration. 

1295.  In  this  investigation,  I  will  first  inquire  into  the  nature 
of  the  case,  which  is  supposed  to  require  this  operation;  second, 
determine  the  situation,  and  condition  of  the  parts,  after  the  in- 
version is  complete;  and  third,  investigate  the  cases,  which  pur- 
port to  be  cases  of  complete  inversion,  and  in  which,  the  uterus 
is  said  to  have  been  restored  to  its  natural  situation. 

1296.  I.  It  has  been  always  found,  when  the  greater  bulk  of 
the  uterus  has  passed  the  os  uteri,  that  the  most  alarming  symp- 
toms inunediately  ensue;  and  if  the  parts  be  not  speedily  relieved 
from  this  unnatural  situation,  the  case  will  almost  constantly  ter- 
minate in  death.  (See  case  first.)  The  terrible  symptoms  just 
spoken  of,  arise  from  that  portion  of  the  uterus,  which  is  below 
the  circle  of  the  os  uteri,  becoming  strangulated  by  the  firm  and 
obstinate  contraction  of  the  neck,  by  which  it  is  now  surrounded,  to 
say  nothing  of  the  new  situation  of  this  organ — namely,  its  inter- 


476  INVERSION  OF  THE  UTERUS. 

nal  surface  forced  to  become  the  external.  Everybod)^  conver- 
sant with  the  anatomy  of  the  uterus  after  parturition,  will  ac- 
knowledge, that  the  portion  of  the  uterus  which  passes  through 
the  mouth  in  a  case  of  inversion,  is  vastly  greater  than  that  por- 
tion which  constitutes  the  neck;  especially,  when  the  latter 
has  a  disposition  to  contract  by  virtue  of  its  tonic  power.  Now, 
this  contraction  must  take  place  before  the  threatening  symptoms 
can  show  themselves;  consequently,  the  part  which  is  protruded 
must  very  much  exceed  in  size  that  through  which  it  has  escap- 
ed. For  the  body  and  fundus  of  tlie  uterus,  even  in  the  natural 
relation  of  these  parts  to  each  other,  are  much  larger  than  the 
neck  of  this  organ;  and  when  they  are  newly  freed  of  their  con- 
tents, and  are  fully  engorged  with  blood,  those  proportions  are 
increased;  and  such  is  the  disposition  of  the  neck  of  the  uterus  to 
contract,  that  in  most  instances  it  is  found  to  be  small  and  resist- 
ing, very  soon  after  deliver}';  while  the  body  and  fundus,  though 
in  the  healthy  exercise  of  their  powers,  remain  for  a  long  time 
comparatively  large.  It  must  therefore  follow,  that  unless  the 
bulk  of  the  body  and  fundus  can  be  reduced  to  the  size  of  the 
constricting  circle  of  the  os  uteri,  or  the  constricting  circle  be 
enlarged  to  a  dimension  equal  to  that  of  the  body  and  fundus, 
one  cannot  be  made  to  pass  through  the  other. 

1297.  II.  The  situation  and  condition  of  the  parts,  after  the  m- 
version  is  complete,  is  very  different  from  what  they  were  before 
this  had  taken  place.  These  changes  consist,  1st.  In  the  entire 
removal  of  the  constriction,  in  consequence  of  the  neck  of  the 
uterus  itself  becoming  also  inverted;  and  consequently,  every 
portion  of  the  body  and  fundus  being  removed  below  its  grasp. 
2d.  By  the  capacity  of  the  os  uteri  being  still  more  diminished; 
as  it  is  no  longer  distended  by  a  portion  of  the  body  of  this  organ; 
consequentl}',  the  body  and  fundus  are  increased  in  size,  if  not 
positively,  certainly  relatively,  while  the  capacity  of  the  mouth 
is  diminished;  as  the  latter  naturally  becomes  smaller  than  the 
former.  The  uterus  will  now  resemble  a  pear  suspended  by  its 
stem;  (see  Plate  XVII.)  and  the  relative  proportion  between  its 
extremities  is  pretty  much  in  the  same  degree,  as  that  which  ex- 
ists between  the  two  extremities  of  a  pear. 

129S.  The  uterus  in  a  state  of  complete  inversion,  is  suspended 
by  the  upper  portions  of  the  vagina,  and  can  be  pushed  a  consi- 
derable distance  upwards  into  the  pelvis,  if  we  press  its  fundus 
in  tliat  direction;  or,  by  a  contrary  force,  it  may  be  dragged  to 


INVERSION  OF  THE  UTERUS.  477' 

some  distance  beyond  the  os  externum;  consequently,  it  is  capa- 
ble of  considerable  motion. 

1299.  Now,  in  order  that  the  body  and  fundus  may  be  restored 
after  inversion,  they  must  return  through  the  contracted  mouth  of 
the  neck  of  the  uterus;  and  with  a  view  to  explain  the  nature  of 
the  difficulty  that  must  be  encountered  in  the  attempt  to  perform 
this  operation,  let  us  take  an  example  from  a  suspended,  pear- 
shaped,  gum  elastic  bottle;  and  the  material,  by  which  it  is  sus- 
pended, capable  of  bearing  but  a  limited  degree  of  force.  Let  us 
imagine,  however,  in  our  example,  that  we  wish  either  to  produce 
its  inversion,  or  to  restore  it,  after  it  has  been  inverted.  If  we 
adopt  the  latter,  (for  it  is  more  analogous,)  we  must  take  for 
granted,  that  the  neck,  from  some  cause  or  other,  had  lost  its 
power  of  resistance,  and  had  permitted  the  fundus  and  body  to 
pass  through  it;  and  that  now,  it  is  our  design  to  restore  them; 
but  at  a  time  when  the  neck  has  recovered  its  powers,  and  is  now 
in  a  state  of  contraction,  or  resistance.  I  will  ask  any  man  of  can- 
dour, if  under  such  circumstances  he  would  think  it  possible  to 
restore  the  fundus  and  body;  (if  we  may  so  term  the  two  portions 
of  the  gum  elastic  bottle ;)  we  are  well  persuaded  that  he  will  not, 
and  for  the  following  reasons:  1st.  Because  the  neck  of  the  uterus, 
or  of  the  bottle,  if  we  pursue  the  example,  is  now  nearly,  or  quite 
at  its  minimum  size,  while  the  body  and  fundus  preserve  a  greater 
size  than  natural;  and  consequently  are  much  larger  than  the  neck. 

1300.  2d.  Because  there  is  too  great  a  disproportion  between 
the  size  of  the  body  to  be  passed,  and  the  opening  which  is  to 
permit  it  to  do  so,  if  the  natural  relation  of  the  parts  exist,  which 
in  this  instance  must  be  admitted. 

1301.  3d.  Because,  though  it  might  be  possible  to. make  the 
mouth  of  the  uterus  yield,  by  a  sufficient  force  being  directly  ap- 
plied to  it,  yet  we  cannot  in  this  case  take  advantage  of  this  pro- 
bability ;  since  our  force  can  only  be  applied  in  one  way,  and  that 
way  an  imperfect  one;  namely,  by  urging  the  fundus  towards 
the  constriction,  and  attempting  to  make  it  pass  the  contracted 
mouth  of  the  uterus.  But  in  this  consists  one  of  the  difficulties 
of  the  operation ;  for,  be  the  body  and  fundus  of  the  uterus  either 
firmly  contracted,  or  comparatively  flaccid,  great  difficulty  would 
be  experienced  in  pressing  the  centre  of  the  fundus  towards  the 
axis  of  the  mouth,  if  it  be  even  practicable,* 

•  In  two  cases  of  inversion,  one  complete  and  the  other  nearly  so,  I  persever- 
ed in  the  attempt  at  reduction,  nearly  two  hours.     The  plan  I  pursued,  in  both, 


478  INVERSION  OP  THE  UTERUS. 

1302.  4th.  Because,  if  the  fundus  be  thus  carried  to  the  mouth 
of  the  uterus,  it  cannot  be  made  to  pass,  from  the  excess  of  its 
bulk,  and  the  resistance  of  the  contracted  mouth,  unless  a  force  be 
employed  that  shall  overcome  all  opposition;  and  if  this  be  ap- 
plied, the  vagina  at  its  union  with  the  neck  of  the  uterus  will 
yield  sooner  than  the  mouth  of  the  uterus. 

1303.  5th.  Because,  Drs.  Denman,  Hunter,  and  Ford,  have 
(1285)  all  confessed,  they  failed  in  every  attempt  they  had  made 
lo  restore  the  fundus  in  a  complete  inversion;  and  I  will  most 
candidly  add,  that  the  same  failure  has  attended  my  exertions, 
after  the  best  directed,  and  the  most  persevering  endeavours, 
I  could  devise. 

1304.  6th.  Because,  no  pressure,  or  force  however  well-direct- 
ed, hovvever  long-continued,  can  diminish  the  fundus  and  body 

and  I  believe  It  is  the  only  one  which  promises  success,  was,  after  grasping  the 
bulk  of  the  protruded  part  firmly,  but  gently,  for  half  an  liour,  with  the  inten- 
tion of  dispossessing  it  as  much  as  possible  of  blood,  and  thereby  reducing  its 
bulk,  I  then  placed  the  ball  of  my  thumb  to  the  centre  of  the  fundus,  and  gently 
and  steadily  pressedit  in  the  direction  of  the  axis  of  the  mouth.  After  contin- 
uing this  pressure  for  a  long  time,  I  found  my  thumb  buried  in  an  indentation  of 
about  an  inch  in  depth,  which  encouraged  me  to  persevere  a  considerable  time 
in  the  same  kind  of  force.  At  one  time  I  thought  my  efforts  were  about  to  be 
crowned  by  success,  as  I  believed  I  was  making  the  fundus  encroach  upon  the 
circle  through  which  it  must  pass,  before  it  could  be  reduced.  But  I  was  too 
soon  convinced  my  hopes  were  delusive;  for  upon  an  accurate  examination  of 
my  proceedings,  I  foimd  my  supposed  progress  was  altogether  owing  to  the 
straining  of  the  os  uteri  at  its  connection  with  the  vagina;  and  I  was  obliged  to 
abandon  an  enterprise  that  at  one  moment  I  had  flattered  myself  was  about  to 
be  successful,  as  my  patient's  strength  was  fast  weai'ing  away.  The  only  re- 
maining chance,  as  I  believed,  was  to  complete  the  inversion;  this  I  did  with- 
out difficulty.  It  afforded  relief;  but  the  patient  was  too  much  exhausted  to 
profit  by  it;  she  died  thirty-six  hours  after.  It  maybe  proper  to  mention  that 
when  I  first  saw  this  patient,  she  was  nearly  exhausted  by  hemorrhage  and  suf- 
fering and  almost  pulseless.  After  completing  the  inversion,  she  seemed  to 
improve  as  a  moderate  reaction  took  place;  but  it  was  short  lived;  she  sank 
after  this  time  not  to  be  again  roused.  The  other  case  which  happened  within 
a  short  time,  (April,  1827,)  the  patient  was  not  much  exhausted;  as  the  mid- 
wife became  early  alarmed,  and  I  was  sent  for  soon  after  the  accident.  I  have 
reason  to  believe,  the  midwife  completed  the  inversion  by  dragging  at  the  pla- 
centa which  brought  the  fundus  of  the  uterus  throug-h  the  os  externum.  This 
was  reduced  after  a  few  minutes,  by  gently  and  firmly  pressing  it  upwards  in 
the  direction  of  the  vagina.  I  persevered  in  this  case,  as  industriously  and  as 
steadily  as  in  the  other,  and  with  no  better  success.  Tliis  woman  labours  under 
a  considerable  bloody  discliarge,  but  which  is  gradually  diminishing;  and  is  re- 
covering strength  slowly .f 

f  I  have  seen  this  patient  within  a  few  days,  (Oct.  1827.)     She  has  nearly  recov- 
ered her  usual  strength,  but  is  still  pale  and  sickly  in  look. 


INVERSION  OF  THE  UTERUS.  479 

below  the  natural  size  of  the  mouth  of  the  uterus,  when  this  is  in 
a  state  of  contraction. 

1305.  III.  I  shall  now  examine  such  cases  as  purport  to  be  in- 
stances of  reduction,  after  "  complete  inversion."  From  what 
I  have  already  said  upon  this  subject,  it  will  be  seen,  that  a  very 
indistinct  notion  has  been  entertained  of  the  complete  "inversion 
of  the  uterus;"  and  if  our  definition  be  referred  to,  (12G6)  and 
admitted,  as  it  certainly  should  be,  I  think  it  will  be  easily  shown, 
that  no  one  instance  in  which  it  is  said  re-inversion  was  eflfect- 
ed,  was  a  case  of  "  complete  inversion."* 

1306.  We  have  already  given  our  reasons  for  not  allowing 
Mr.  White's  case  to  have  been  one  of  "  complete  inversion  of  the 
uterus,"  (1286)  and  the  same  argument  will  apply  to  all  such  as 
purport  to  be  of  this  kind,  as  far  as  I  have  had  it  in  my  power  to 
examine  them.  Thus  we  find  a  case  stated  in  the  ''  New  England 
Journal,"  Vol.  I.  third  series,  p.  264,  which  is  called  a  case  of 
complete  inversion,  and  in  which  reduction  was  effected.  The 
relator  says,  "the  attending  physician  pulled  gently  at  the  cord; 
immediately  the  placenta  pushed  forward,  protruded  at  the  exter- 
nal orifice,  and  was  followed  by  the  uterus,  completely  inverted. 
The  placenta  still  adhering,  he  separated  it  with  the  fingers,  and 
returned  the  organ  as  he  siqiposed  into  its  proper  placeA  On 
Saturday,  (the  day  after  the  delivery,)  the  patient  was  taken  out 
of  bed,  when  the  uterus  immediately  protruded  out  of  the  body, 

followed  by  a  copious  discharge  of  blood.     Dr.  was  in  a  few 

minutes  called  in,  and  pushed  the  protruded  uterus  within  the 
vagina,  supposing  that  this  was  all  that  was  necessary  to  be  done, 
or  rather  concluding  he  had  returned  the  prolapsed  part  into  its 
original  situation.  The  loss  of  blood  was  considerable,  so  much 
so  as  to  jjroduce  syncope,  from  which  she  was  gradually  restored 
by  cordials,  friction,  and  volatiles.  A  moderate  discharge  still  con- 
tinued to  flow  till  about  twelve  o'clock  at  night,  when  the  pulse 
began  to  sink,  accompanied  with  faintness  and  great  prostration 
of  strength."  "Upon  examination,"  says  the  relator,  "I  found  the 
uterus  completely  inverted,  occupying  the  whole  of  the  vagina, 
the  neck  reaching  above  the  pubis.""  He  then  declares,  the  fundus 
by  proper  manipulation,  was  restored.  This  case,  however,  proved 
eventually  fatal. 

•  Ml*.  Nevvnham  makes  the  absence  of  the  neck  surrounding  the  prolapsed 
part  essential  to  a  complete  inversion. 

f  We  presume  he  intends  to  be  understood,  by  the  words  "returned  the  or- 
gan into  its  pi-oper  place,"  that  he  restored  the  protruded  body  and  fundus  to 
their  natural  situations. 


480  INVERSION  OF  THE  UTERUS. 

1307.  This  case,  we  may  safely  declare,  was  not  one  of  "com- 
plete inversion"  of  the  uterus;  and  for  the  following  reasons: — 
First,  because  the  phenomena  were  not  those  which  accompany 
a  complete  inversion;  there  was  too  much  haemorrhage,  and  too 
many  distressing  symptoms.*  Second,  because,  the  author  ex- 
pressly and  conclusively  determines  this  point,  by  saying,  "Me 
neck  of  the  uterus  reached  above  the  ptibis."  I  have  already 
pointed  out  the  situation  of  the  mouth  and  neck  of  the  uterus  in 
the  complete  and  incomplete  inversion  of  the  uterus,  in  par.  1285. 

1308.  In  a  review  of  my  "Essays  on  various  subjects  connect- 
ed with  Midwifery,"  by  a  writer  in  Vol.  III.  No.  II.  p.  157,  of  the 
third  series  of  the  New  England  Journal,  &.c.  I  tind  the  following 
observations  in  reference  to  my  proposal  of  converting  a  partial 
inversion  into  a  complete  inversion,  when  there  is  no  chance  of 
restoring  it,  and  the  symptoms  are  threatening.  "  The  practice 
in  this  case,"  (case  second,)  "  was  successful  in  rescuing  the  pa- 
tient from  imminent  danger.  It  left  her  the  subject  ofiywerted 
uterus  the  remainder  of  life.  This  last  fact  makes  the  question  of 
adopting  Dr.  D.'s  method  a  very  serious  one,  and  in  considering 
this  question  we  are  met  by  others.  Is  there  no  chance  of  reduc- 
ing the  uterus  after  the  stricture  has  been  removed  in  the  man- 
ner proposed  above,  and  should  not  its  reduction  be  attemjjted 
either  immediately  after,  or  as  soon  as  the  patient  is  enough  re- 
cruited to  endure  the  fatigue,  and  pain  of  a  trial?  A  case  has 
been  related  to  us  of  at  least  two  days  standing,  in  which  the  phy- 
sician having  grasped  the  uterine  tumour  in  his  hand,  gradually 
compressed  it,  and  after  a  long-continued  effort,  succeeded  in  re- 
ducing this  organ.  This  was  related  by  the  physician  who  per- 
formed the  operation.  The  inversion  here  was  complete^  and  this 
may  make  such  a  difference  between  the  cases  as  to  render  it  ques- 
tionable whether  similar  means  would  be  applicable  to  both." 

1309.  This  critique  involves  a  number  of  separate  propositions, 
which  we  shall  notice  in  their  order.  First,  "  It  left  her,"  (the 
patient,)  "the  subject  of  inverted  uterus  for  the  remainder  of 
life."  The  question  which  presents  itself  to  meet  this  objection, 
is  simply,  whether  an  accoucheur  is  not  bound  to  avert  death 

•  "  But  it  is  worthy  of  notice  that,  frequently,  complete  inversion  is  not  ac- 
companied with  haemorrhage."  Burns,  p.  516.  This  obtained  in  Dr.  Hamil- 
ton's case,  and  tliis  is  ageeable  to  the  observations  of  others.  In  Dr.  Denman's 
case  II.  which  was  a  case  of  complete  inversion,  he  says,  "  tlic  hemorrhage  was 
not  profuse.'- 


INVERSION  OP  THE  UTERUS.  481 

when  it  is  in  his  power?  or,  at  all  events,  is  he  not  bound  to  do, 
at  the  moment  he  is  obliged  to  decide,  the  best  he  can  for  his 
patient?  This  certainly  will  be  answered  in  the  affirmative: 
for  he  has  no  right  to  inquire  whether  death  might  not  be  pre- 
ferable to  life,  upon  the  terms  he  can  give  that  life.  For  if  he 
decide  that  it  is,  and  he  permit  his  patient  to  die,  rather  than  sub- 
ject her  to  the  penalty,  that  the  preservation  of  her  life  will  im- 
pose upon  her,  he  is  guilty  of  a  species  of  murder.  It  is  there- 
fore decidedly  his  duty,  his  imperious  duty,  to  preserve  life 
when  it  is  in  his  power,  be  the  terms  of  that  preservation  what 
they  may. 

1310.  If  this  be  granted,  it  will  also  be  ceded  I  trust,  that 
I  was  acting  strictly  in  the  line  of  my  duty,  in  affording  the  only 
apparent  chance  for  life,  or  even  of  comfort,  to  an  almost  expir- 
ing woman. 

1311.  That  it  was  an  experiment,  is  granted;  and  its  success 
was  yet  to  be  proved;  it  turned  out  fortunately,  and  rescued  the 
patient  I  honestly  believe  from  death;  and  if  the  history  of  this 
case  be  carefully  read,  (case  second,)  it  will  be  seen,  that  it  was 
considered  altogether  hopeless,  after  the  attempt  at  reduction, 
which  was  conducted  with  all  the  little  ability  I  was  master  of, 
had  proved  fruitless ;  and  that  the  patient  might  be  considered 
in  "articulo  mortis;"  I  therefore  think  there  can  be  little  doubt, 
that  I  did  the  best  the  situation  would  permit. 

1312.  I  would  ask,  for  information,  what  better,  could  have 
been  done  under  the  existing  circumstances?  for  the  patient  was 
almost  expiring;  and  would  have  very  quickly  died  if  relief  had 
not  been  afforded.  The  attempt  at  restoration,  the  only  one  on 
which  we  could  rely,  it  is  seen  had  failed ;  the  "  anceps  reme- 
dium,''^  presented  itself;  and  it  proved  successful.  But  let  me 
now  be  clearly  understood  upon  this  subject,  as  declaring,  that 
the  proposition  in  question,  is  never  to  be  acted  upon,  but  as  the 
dernier  resource ;  and  that  I  have  never  proposed  it  but  as  such, 
will,  I  think  distinctly  appear,  if  what  I  have  said  be  carefully 
read. 

1313.  It  is  asked,  "  is  there  no  chance  of  reducing  the  uterus 
after  the  stricture  is  removedV^  I  would  ask  in  turn,  can  the 
stricture  be  removed?  Has  the  writer  ever  known  it  removed? 
If  he  have  not,  I  think  the  question  answers  itself,  since  we  have 
no  control  over  it;  and  we  fear  we  cannot  have,  as  a  little  reflec- 
tion on  the  situation,  and  functions  of  the  parts,  will  show  almost 

Gl 


482  INVERSION  OP  THE  UTERUS, 

its  impossibility;  for  which  reason  I  am  decidedly  of  opinion  that 
a  "  complete  inversion"  never  has  been  reduced.  It  is  true  we 
may  suppose  a  case,  and  then  deduce  the  possibility  of  restora- 
tion in  complete  inversion — we  may  imagine  the  neck  of  the 
uterus  to  be  in  a  state  of  relaxation  ;  and  if  it  be  so,  no  difficulty 
in  the  restoration  of  the  fundus,  presents  itself.  But  let  this  con- 
dition be  proved  to  exist,  before  we  speculate  upon  the  advan- 
tages that  v.'ould  result  from  such  a  state  of  things.  See  par. 
1268  and  1339,  &c.  and  fig.  XVII. 

1314.  It  will  be  seen  at  once,  by  reference  to  the  structure  of 
the  parts  concerned  in  this  accident,  that  the  structure  in  question 
is  nothing  more  nor  less,  than  a  natural,  or  functional  condition 
of  the  OS  uteri ;  for  a  state  of  contraction  is  thp  natural  state  of 
this  part,  when  its  functional  powers  are  in  a  healthy  condition; 
conaequently,  it  ahvays  closes  after  the  contents  of  the  uterus  are 
discharged.  It  seems,  that  the  writer  of  the  article  under  consi- 
deration, looks  upon  this  stricture,  "  as  an  accidental  state  of  the 
OS  uteri,  and  that  this  condition  can  be  removed  by  remedial 
agents ;"  than  which  in  our  opinion,  there  can  be  no  greater  error. 
If  this  <' stricture"  was  the  effect  of  spasm,  or  of  some  accidental 
state  of  the  os  uteri,  we  might  perhaps,  find  a  remedy  for  this 
unfortunate  condition  of  the  part;  or  it  might,  after  a  given  time, 
relax  itself;  but  when  it  is  well  known  to  be  the  natural  result 
of  its  structure,  and  that  nothing  but  force  can  possibly  overcome 
it,  we  may  look  in  vain,  I  fear,  for  remedies  to  relax  it. 

1315.  If  the  OS  uteri  were  flaccid  during  an  inversion,  the 
chance  of  restoration  would  be  greater,  nay  nearly  certain  ;  but 
as  this  condition  can  only  be  the  result  of  a  diseased  state  of  this 
part,  it  will  only  take  place  from  an  accidental  combination  of 
circumstances,  which  we  can  neither  command,  nor  control. 
The  only  agent  we  have  at  command,  is  mechanical  force  ;  now, 
we  know,  that  this  power  can  very  rarely  be  suecessfuly,  or  even 
safely  employed,  for  the  reason  above  suggested,  (par.  1300,  1301, 
1302,  1303,  &c.)  I  shall  mention,  however,  presently,  that  this 
relaxed  condition  of  the  os  uteri,  sometimes  exists. 

1316.  But,  with  a  view  to  render  this  suggestion  certain;  or 
at  least  occasionally  successful,  it  is  stated  in  the  gross,  that  re- 
storation had  been  performed  after  complete  inversion,  by  a  phy- 
sician who  gave  the  account  himself.  He  says,  that  he  had  re- 
stored the  fundus  after  the  lapse  of  forty-eight  hours,  and  that  the 
"inversion  was  complete."     We  are  not  favoured  with  any  of 


INVERSION  OF  THE  UTERUS.  483 

the  particulars  of  this  case  to  prove  it  to  have  been  complete;  we 
are  obliged  to  abide  by  a  bare  ipse  dixit,  which  seems  to  be  at 
once  contradicted,  by  the  very  mode  employed  for  the  reduction, 
as  we  shall  attempt  to  show.  See  fig.  XVI. 

1317.  But  before  we  proceed  farther,  let  us  observe,  that  the 
term  "  complete  inversion"  has  almost  always  been  vaguely  em- 
ployed. When  the  fundus  of  the  uterus  escapes  through  the  os 
externum,  it  is  called  by  Drs.  Denman,  Merriman,  Mr.  Burns, 
M.  Leroux,  and  others,  a  complete  inversion  of  the  uterus;  there- 
by, making  the  situation  of  the  fundus  the  distinctive  sign  of  a 
complete  inversion,  instead  of  the  condition  of  the  neck  of  the 
uterus.  Now  if  this  definition  be  admitted,  we  may  look  for  many 
instances  of  the  reduction  of  a  "complete  inversion,"  without  a 
single  genuine  instance  occurring  to  authenticate  the  success  of 
the  operation.  For  I  have  seen  more  than  one  instance  of  partial 
inversion,  in  which  the  fundus  was  protruding  the  external  parts; 
and  could  cite  many  more. 

131S.  The  reviewer  farther  states,  that  "there  was  a  period 
in  the  above  case,  (case  second,)  in  which  reduction  might  have 
been  performed."  This,  however,  is  merely  opinion;  and  cannot 
be  either  proved  or  disproved,  yet  with  a  view  to  this,  he  says, 
*<the  woman  was  delivered  by  a  midwife  on  Friday.  Dr.  Devvees 
and  Dr.  Atlee  were  not  called  until  the  Tuesday  following.  These 
facts  are  worthy  of  notice,  for  should  partial  inversion  occur,  and 
symptoms  of  strangulati-on  come  on,  soon  after  delivery,  and  an 
insurmountable  obstacle  seem  to  exist  to  reduction;  might  not 
some  other  means  of  treatment  be  adopted,  than  the  method  of 
the  author?  Would  full  opiates,  warm  bathing,  a7id  even  blood- 
letting, be  advisable,  in  the  first  instance;  followed  by  attempts  at 
reduction,  when  the  effects  were  present,  of  all  these  means,  or  of 
some  of  them?"  p.  158,  loc.  cit. 

1319.  In  answer  to  the  above  questions,  I  should  hold  it  doubt- 
ful, whether  the  writer  of  the  review  had  ever  witnessed  a  case 
of  inverted  uterus?  If  he  had,  I  think  he  would  not  have  pro- 
posed ivarm  baildng,  or  blood-letting,  where  symptoms  of  stran- 
gulation had  come  on.  He  would  have  known  that  an  over-power- 
ing flooding  almost  alwaj^s  attends  a  partial  inversion,  and  for 
which  the  warm  bath  would  be  considered  a  very  doubtful  reme- 
dy, to  say  the  least  of  it.  He  would  also  have  known,  that 
faintness,  exhaustion,  vomiting,  an  almost  extinct  pulse,  are  sure 
to  accompany  a  strangulated  uterus,  and  consequently,  that  blood- 
letting is  not  indicated  or  to  be  thought  of.     Opium  is  the  only 


484  INVERSION  OF  THE  UTERUS. 

one  of  his  proposed  remedies  that  can  be  used  with  advantage; 
and  this  has  always  been  given  in  large  and  frequent  doses,  the 
instant  severe  pain  has  shown  itself;  but  with  no  other  advantage, 
as  far  as  I  have  seen,  than  to  diminish  pain;  it  cannot  relax  the 
contracted  os  uteri. 

1320.  He  however  in  a  subsequent  sentence,  says,  "the  situa- 
tion of  the  author's  patient  seems  to  have  been  truly  desperate, 
and  to  have  fully  warranted  the  bold  and  novel  treatment  adopt- 
ed." p.  158.  We  are  perfectly  aware  of  all  the  evils  that  will 
arise  from  this  new  relation  of  the  parts  of  the  uterus;  and  also 
that  nothing  short  of  an  absolute  necessity  can  justify  the  execu- 
tion of  the  plan  proposed. 

1321.  If  it  be  asked,  are  there  no  instances  of  the  reduction 
of  the  uterus  under  desperate  circumstances?  and  if  we  are  to 
doubt  the  histories  of  such  cases  as  purport  to  have  been  success- 
ful, where  a  number  of  days  have  elapsed  after  the  inversion  had 
taken  place?  I  say  yes  to  the  first  question;  and  I  would  certainly 
say  in  answer  to  the  second,  that  we  are  not  to  doubt  the  truth 
of  such  histories,  so  far  as  the  opinions  of  the  relaters  constitute 
the  truth.  By  these  concessions,  however,  I  am  not  to  be 
charged  with  deserting  the  position  1  have  taken,  for  though  I 
admit  everything  that  the  above  questions  in  their  general  sense 
require,  I  must  still  insist  that  hitherto,  I  have  not  met  with  an 
instance  in  my  own  practice,  nor  in  that  of  any  one  else,  of  a 
well  established  case  of  "complete  inversion,"  in  which,  by  any 
efforts  or  perseverance,  the  fundus  of  the  uterus  has  been  placed 
in  situ.  I  have  no  hesitation  to  believe  that  the  os  uteri  may 
remain  for  some  time  uncontracted,  or  after  some  time  to  be- 
come relaxed  after  such  contraction,  in  partial  inversion;  and 
that  in  such  cases,  a  well-directed  measure  may  become  success- 
ful. But  it  must  be  remembered,  where  such  instances  of  suc- 
cess have  occurred,  there  was  an  absence  of  all  severe  and  threat- 
ening symptoms;  an  evidence  that  the  neck  of  the  uterus  could 
not  be  very  strictly  girding  the  prolapsed  portion.  One  of  the 
most  remarkable  and  instructive  cases  of  this  kind,  is  related  by 
Dr.  Teallicr,  in  Journal  Universel,  for  Nov.  1823. 

"A  Madame  R.  twenty-five  years  of  age,  was  delivered  on  2d 
of  September,  1823,  after  a  labour  of  thirty-six  hours.  The  pla- 
centa was  extracted  without  difliculty,  and  the  patient  was  put 
to  bed  comfortably.  She  continued  pi'etty  well  until  the  12th, 
when  Dr.  T.  was  called  at  one  o'clock  in  the  morning  to  his  pa- 
tient, who,  in  making  violent  efforts  to  pass  the  contents  of  the 


INVERSION  OF  THE  UTERUS.  485 

rectum,  felt  a  bulky  mass  of  flesh  descend  through  the  vagina, 
which,  though  it  did  not  produce  much  inconvenience  at  the 
time,  was  followed  in  about  an  hour  by  great  pain  in  the  belly, 
the  displaced  parts,  and  in  the  groins,  with  a  strong  effort  to  vo- 
mit, and  a  sensation  of  faintness.  She  was  much  alarmed,  and 
retired  again  to  bed,  supporting  between  her  thighs  a  smooth 
tumour  of  a  deep  red  colour,  of  the  size  and  shape  of  a  large  pear 
—its  large  extremity  was  resting  on  the  thighs,  its  pedicle  was 
tied  within  the  labia.  Dr.  T.  proceeded  to  the  reduction  by  re- 
turning the  tumour  into  the  vagina,  but  in  endeavouring  to  re- 
store it  to  its  natural  situation,  the  hardness,  and  the  contraction 
of  the  neck,  rendered  it  impossible;  the  sensibility  of  the  oro-aii 
being  so  much  augmented,  that  the  least  pressure  produced  vio- 
lent pain.  Dr.  T.  suspended  his  attempts,  with  the  intention  to 
renew  them  when  circumstances  were  more  favourable.  The 
patient  was  placed  upon  her  back;  the  pelvis  elevated ;  the  thighs 
closed  ;  and  emollient  fomentations  and  injections  were  employed 
— a  rigid  diet  was  observed  for  the  first  twenty-four  hours.  There 
was  no  haemorrhage,  but  little  pain  in  the  abdomen,  or  fever. 

«  On  the  evening  of  the  13th  an  obstinate  cough  came  on,  at- 
tended with  fever,  and  some  pain  in  the  abdomen;  but  a  laro-e 
bleeding  on  the  14th  removed  these  symptoms.  On  the  ISth,  the 
condition  of  the  patient  continuing  favourable,  and  Dr.  T.  finding 
the  tumour  to  soften  and  become  smaller,  determined  on  another 
attempt  to  reduce  it  to  its  natural  situation,  in  which  he  succeed- 
ed in  one  hour  and  a  half,  making,  during  this  time,  a  moderate 
and  continued  pressure  with  the  hand.  No  symptoms  of  conse- 
quence followed,  that  were  ascribable  to  the  accident." 

1322.  This  case  is  remarkable  on  several  accounts:  first.  The 
uterus  contracting  healthily  immediately  after  delivery,  and  con- 
tinuing in  this  condition  for  several  days;  second.  An  entire  re- 
laxation of  this  organ  taking  place  ten  days  after  delivery;  for 
though  violent  efforts  were  made  to  empty  the  rectum,  yet  these 
efforts  could  not  be  the  primary  cause  of  the  inversion;  and  that 
for  during  this  time  the  uterus  must  have  passed  through  the  os 
externum,  and  have  required  the  relaxation  of  the  neck  and  other 
portions  of  the  uterus;  and  for  the  irritation  of  the  rectum,  and 
the  consequent  action  of  the  abdominal  muscles,  could  not  induce 
this  condition,  though  they  might  contribute  eventually  to  the 
inversion.  It  is  therefore,  more  probable  that  the  inverted  uterus 
was  the  first  cause  of  these  efforts,  by  pressing  powerfully  upon 


486  INVERSION  OF  THE  UTERUS. 

the  rectum;  and  the  inversion  confirmed,  by  the  straining  it 
created. 

1323.  Third.  The  entire  contraction  of  the  uterine  vessels;  as 
it  is  expressly  stated,  there  was  no  hEcmorrbage;  and  it  is  also 
mentioned,  the  tumour  was  "  smooth,"  which  would  not  have 
been  the  case,  were  the  uterus  not  well  contracted.* 

1324.  Fourth.  The  gradual  subsiding  of  the  few  unpleasant 
feelings,  and  the  reduction  of  the  uterine  tumour,  after  a  short 
time;  manifesting  the  relaxation  of  the  neck  of  the  uterus,  so  as 
to  admit  the  repassing  of  the  inverted  portions.  For  it  is  evident 
that  this  must  have  happened,  since  there  were  a  few  distressing 
symptoms,  immediately  after  the  inversion,  such  as  pain,  sickness, 
and  faintness,  which  were  certainly  owing  to  the  body  and  fundus 
being  slightly  strangulated,  but  which  soon  subsided,  by  ihe  mouth 
of  the  uterus  relaxing  sufficiently,  to  permit  the  reduction  of  the 
inverted  portions. 

1325.  Fifth.  It  proves  that  in  "partial  inversion,"  reduction 
may  take  place  under  certain  circumstances  and  by  proper  man- 
agement, at  least  six  days  after  the  accident.  For  we  must  insist 
that  this  was  a  case  of  ^'partial  inversion,"  as  the  neck  of  the 
uterus  is  charged  with  the  difficulty  of  reduction,  on  the  first  at- 
tempt for  this  purpose. 

1326.  In  the  inversion  the  uterus  is  the  very  reverse  of  its  na- 
tural situation;  its  internal  face  now  becomes  the  external;  while 
the  external  or  peritoneal  surface,  becomes  the  internal,  or  the 
uterine  cavity,  if  we  may  so  term  it — it  is  probable  that  the  ova- 
ries, tubes  and  broad  ligaments  will  be  included  in  this  space.  Dr. 
Denman  informs  us  these  surfaces  do  not  coalesce.  The  woman 
may  menstruate  from  the  now  external  surface. 

Case  First. 

On  the  2d  of  July,  1807,  at  ten  o'clock,  A.  M.  I  was  called  to 

the  wife  of  Samuel  N ,  in  labour  with  her  first  child.     Her 

pains  were  weak  and  irregular,  but  pretty  frequent;  presentation 
perfectly  natural.  As  everything  appeared  promising,  I  left  her 
to  the  care  of  her  midwife.     At  four  o'clock,  P.  M.  she  was  sud- 

*  Smoothness  is  necessarily  relative — for  we  cannot  believe,  that  this  condi- 
tion of  the  tumour  could  exist  but  in  a  moderate  degree;  for  however  firmly 
the  uterus  may  have  contracted,  its  internal  (now  its  external)  surface  could  not 
but  display  to  a  greater  or  less  extent,  a  roag-l\  surface,  especially  at  that  portion, 
on  whicJi  the  placenta  had  been  placed. 


INVERSION  OF  THE  UTERUS.  487 

denly  delivered — considerable  hscmorrhage  with  faintings  follow- 
ed. I  was  again  sent  for,  but  did  not  see  her  nntil  six  o'clock,  as 
she  lived  at  some  distance  from  the  city.  T  found  her  without 
pulse,  cold,  and  covered  with  perspiration;  with  laborious  and 
hurried  breathing;  the  placenta  not  delivered,  and  the  hemor- 
rhage continuing.  I  ordered  her  such  remedies  as  appeared  most 
pressingly  indicated,  and  immediately  examined  her  per  vaginam. 
I  found  the  placenta  just  within  reach  of  the  finger,  and  attempt- 
ed to  withdraw  it,  but  it  gave  great  resistance  and  extreme  pain. 
1  now  introduced  my  hand,  and  found  a  tumour  resembling  in 
shape  and  size  the  swelling  at  the  bottom  of  the  common  black 
bottle,  and  over  which  the  placenta  was  spread.  This  case  was 
perfectly  new  to  me,  in  a  practical  sense,  although  I  strongly  sus- 
pected the  nature  of  the  accident.  I  searched  for  the  detached 
portion  of  the  placenta^  from  whence  the  flooding  proceeded,  and 
carefully  detached  this  mass  from  the  tumour;  1  then  endeavour- 
ed to  push  up  this  body,  but  quickly  desisted,  from  the  extreme 
pain  it  occasioned,  and  the  uncertainty  that  it  was  the  best  mode 
of  proceeding  to  procure  relief.  My  patient  died  in  half  an  hour. 
1  obtained  leave  to  inspect  the  body,  and  Dr.  Rush  very  kindly 
accompanied  me.  It  proved,  as  I  had  previously  suspected,  to 
be  a  partial  inversion  of  the  uterus.  I  dissected  out  the  uterus, 
which  was  still  so  flaccid,  as  to  be  turned  inside  out  with  as  much 
facility  as  a  soaked  bladder.  The  fundus  dipped  into  the  body 
of  the  uterus  about  three  inches.* 

Case  Second. 

On  Friday,  24th  March,  1808,  at  half  past  five  o'clock  in  the 
morning,  Mrs.  P.  was  delivered  of  a  living  child;  her  waters  dis- 
charged themselves  six  or  seven  hours  previously,  and  before  her 
midwife  was  called.  The  placenta  came  away  spontaneously,  as 
the  midwife  asserted,  and  to  which  the  patient  herself  agreed;  its 
expulsion  was  attended  with  great  pain  and  great  flooding;  she 
vomited  severely  for  an  hour,  and  several  times  fainted  without 
an  abatement  of  the  discharge.     This,  however,  was  eventually 

*  This  case  proves,  what  I  have  stated  above,  that  even  a  depressed  fundus 
may  prove  fatal;  by  the  excess  of  flooding;  and  consequently,  we  cannot  trust 
sucli  cases;  as  we  cannot  insure  the  entire  adhesion  of  the  placenta,  nor  always 
provoke  the  healthy  contraction  of  the  body  and  fundus  of  the  uterus,  so  as  to 
secure  tlie  patient  against  hoemorrhagy. 


488  INVERSION  OF  THE  KTERUS. 

moderated  by  the  acetate  of  lead,  and  perhaps  contraction  of  the 
uterus  itself. 

After  this,  she  continued  pretty  tranquil,  but  weak,  until  Sun- 
day morning,  when  there  was  a  renewal  of  the  haemorrhage,  with 
pains  resembling  those  of  labour.  These  ceased  in  the  afternoon; 
but  she  became  more  alarmingly  ill.  She  now  fainted  frequently, 
and  the  discharge  continued.  In  this  way  she  kept  until  Tues- 
day, at  which  time  I  was  called,  at  the  desire  of  Dr.  Atlee,  whose 
patient  she  now  was.  The  doctor  suspected  the  true  state  of  this 
woman's  case,  and  mentioned  his  opinion  to  me,  to  which  at  first 
I  could  scarcely  assent,  as  almost  all  the  cases  I  had  ever  heard  or 
read  of,  as  well  as  I  recollected,  had  soon  proved  fatal ;  and  the 
case  I  had  witnessed  a  few  months  before,  but  served  to  make  me 
doubt  the  doctor's  representation,  or  rather  opinion.  Here,  if  his 
judgment  were  correct,  was  an  instance  of  inverted  uterus  of  four 
days  standing;  a  case  giving  contradiction  to  all  I  had  heard  or 
believed  on  the  subject.*  I  however  visited  the  patient  by  ap- 
pointment, and  found  her  almost  exhausted — her  pulse  so  frequent 
as  not  to  be  numbered,  and  so  small  as  scarcely  to  be  perceived; 
had  great  difficulty  in  breathing,  and  became  faint  on  the  least 
motion;  insatiable  thirst,  frequent  vomiting,  cold  extremities,  and 
a  continuance  of  uterine  discharge.  I  examined  her,  and  found, 
as  Dr.  Atlee  had  declared,  the  uterus  to  be  inverted.  The  fundus 
was  down  at  the  os  externum,  and  could  readily  be  seen  partially 
covered  with  a  thin  coagulum  of  blood,  when  the  labia  were  se- 
parated. The  places  not  hid  by  this  coagulum,  were  rough  or 
spongy,  and  of  a  dark  brown  colour. 

A  very  dreary  prospect  presented  itself,  by  ascertaining  this 
poor  woman's  situation;  we  believed  death  to  be  inevitable.  But 
one  resource  offered  itself,  namely,  to  attempt  the  reduction  of 
the  fundus,  hoping,  as  the  uterus  had  not  escaped  from  the  vagina, 
the  inversion  might  not  be  so  complete,  as  to  render  this  impos- 

•  Since  writing  the  above,  I  have  strong  reason  to  believe,  that  the  inversion 
did  not  take  place  until  the  morning,  namely,  Sunday;  on  which  there  was  a 
renewal  of  the  flooding,  and  the  occurrence  of  pains  resembling  labour;  and  at 
this  time,  the  uterus  suffered  most  probably  a  universal  atony. 

At  the  time  alluded  to,  from  my  recollections  of  the  opinions  of  others  upon 
tills  subject,  and  the  fatal  case  I  had  recently  witnessed,  my  mind  was  dispos- 
ed to  doubt  the  existence  of  this  disease,  especially  of  several  days'  continuance. 
Farther  experience,  and  refreshing  my  memory  immediately  after  upon  the 
subject  by  reconsulting  authorities,  has  of  course  altered  the  views  I  then  had 
of  its  immediate  fatality. 


INVERSION  OP  THE  UTERUS.  489 

sible.  We  accordingly  proposed  this  attempt  to  the  husband  and 
friends  of  our  patient,  candidly  stating  her  situation,  and  the 
almost  certain  result,  if  relief  was  not  obtained  in  this  way.  They 
without  hesitation  submitted  the  case  to  our  management. 

We  carefully  drew  her  to  the  side  of  the  bed,  and  had  the  knees 
drawn  up  and  supported.  I  gently  introduced  my  hand  under  the 
tumour,  and  gradually  raised  it;  this  gave  me  sufficient  room  to 
examine  the  nature  and  extent  of  the  inversion.  The  instant  I 
raised  the  womb,  there  was  a  large  and  sudden  discharge  of  urine; 
which  gave  still  more  freedom  to  an  examination,  that  was  to  termi- 
nate in  the  disappointment  of  the  hope  of  the  reduction  of  the 
fundus.  I  found  so  much  of  it  had  passed  through  the  mouth  of 
the  uterus,  as  to  render  any  attempt  at  reduction  futile;  and  the 
more  especially,  as  the  tumour  was  augmented  by  its  having  swel- 
led since  it  had  prolapsed.  The  stricture  occasioned  by  the  con- 
tracted mouth  was  readily  felt,  and  was  very  strict.  I  was  ex- 
tremely perplexed  for  the  moment  how  to  proceed,  or  how  to^an- 
nounce  the  failure  of  an  attempt,  which  alone,  at  first  sight,  appeared 
to  promise  success  or  even  relief;  but  it  fortunately  occurred  to  me, 
before  I  withdrew  my  hand,  that  I  might  take  off  the  stricture  by 
inverting  the  uterus  completely.  Agreeably  to  this  suggestion, 
I  grasped  the  tumour  firmly,  and  drew  it  pretty  forcibly  towards 
me,  and  thus  happily  succeeded  in  slipping  the  remaining  portion 
through  the  constricting  mouth.  The  woman  was  almost  instant- 
ly relieved  from  much  of  the  anxiety  and  faintness  she  had  before 
experienced;  but  as  she  was  so  exhausted  by  previous  suffering 
and  discharges,  and  as  the  internal  surface  of  the  uterus  was  now 
exposed  to  the  influence  of  external  air,  I  was  prevented  from 
feeling,  or  giving  the  slightest  encouragement  of  recovery  to  her 
friends ;  but  fortunately  the  event  proved  how  groundless  were 
my  fears;  for  from  this  day,  she  rapidly  recovered,  without  an- 
other alarming  or  troublesome  symptom. 

Milk  was  freely  secreted  on  the  fourth  day  after,  and  continu- 
ed freely.  Our  patient  was  twenty-three  years  of  age,  delicate, 
but  always  healthy,  but  more  especially  so  during  her  preg- 
nancy. 

I  visited  this  patient  to-day,  November  26, 1808,  and  found  her 
at  the  wash-tub,  perfectly  well;  suffers  no  inconvenience  whatever 
from  the  uterus;  menstruated  regularly  for  three  periods;  had 
more  or  less  discharge  of  mucus  tinged  with  blood  for  four  months; 
this  last  four  months  has  had  no  discharge  of  any  kind;  suckles 
62 


490  INVERSION  OF  THE  UTERUS. 

lier  child,  which  is  remarkably  ihriving.  The  uterus  is  so  much 
contracted  as  to  be  no  longer  within  reach  of  her  finger.* 

Case  Third. 

On  the  23d  of  November,  1S08,  Mrs.  G was  suddenly  de- 
livered of  a  large  female  ciiild,  which  breathed  and  cried  freely 
immediately  after  its  birth.  The  funis  was  not  cut  until  after  the 
pulsation  in  the  cord  had  entirely  ceased,  which  was  in  about  ten 
minutes.  After  the  child  was  taken  away,  I  took  hold  of  the 
cord,  and  merely  tightened  it,  on  which  she  begged  me  to  wait, 
as  it  gave  great  pain.  I  however  traced  the  cord  to  the  vagina, 
and  found  at  the  os  externum  a  placenta  I  thought  unusually  dense 
and  large.  On  gently  attempting  to  withdraw  it,  as  I  thought  it 
loose  in  the  vagina,  I  found  uncommon  resistance,  which  1  attri- 
buted to  its  bulk,  and  desisted  from  farther  effort,  hoping  the  ute- 
rus would  by  contracting  push  it  completely  down.  In  this  I 
was  disappointed; — some  haemorrhage  ensued.  I  now  expected 
a  more  than  common  cause  detained  the  'placenta  in  the  vagina, 
and  began  a  more  minute  examination.  I  pierced  the  substance 
of  the  placenta  with  the  forefinger  of  my  left  hand,  and  tightened 
the  cord  with  my  right;  beneath  the  placenta  I  perceived  a  round 
hard  substance,  which  I  but  too  quickly  discovered  to  be  the  fun- 
dus of  tlie  uterus  inverted.  I  immediately  introduced  my  hand 
into  the  vagina,  and  found  the  detached  edge  of  the  placenta  from 
wliich  the  discharge  proceeded.  I  carefully  separated  the  whole 
of  this  mass,  and  withdrew  it  from  the  pelvis  without  the  least 
difficulty.     A  considerable  flooding  ensued. 

As  Mrs.  N 's  case,  (case  first,)  gave  me  a  complete  insight 

of  the  mechanism  of  this  displacement  of  the  fundus  of  the  uterus, 
and  as  I  had  resolved  to  attempt  its  reduction  if  ever  an  opportu- 
nity again  offered,  I  instantly,  after  withdrawing  the  placenta, 
introduced  my  hand,  and  pressed  the  prolapsed  fundus  firmly  with 
the  back  of  my  fingers,  and  carried  it  upwards  in  the  direction 

*  I  was  this  day,  (June  1,  1810,)  called  to  Mrs.  P.  on  account  of  indisposi- 
tion. She  gave  tlie  following  account  of  her  situation:  "  She  had  been  pretty 
regular  ever  since  last  report,  but  for  the  last  few  periods  it  has  been  more 
abundant,  and  is  sometimes  accompanied  by  the  discharge  of  coagula;  it  con- 
tinues longer  than  formerly,  and,  when  it  ceases,  it  is  followed  by  profuse  fluor 
albus."  Ithen  saw  IMrs.  P.  again  in  April,  1818,  and  found  her  enjoying  a  very 
fair  proportion  of  licalth — the  catamenial  discharges  had  ceased  for  the  last  five 
years,  and  she  had  been  a  widow  several  years  past.  She  has  never  been  im- 
pregnated since  her  accident. 


INVEnSION  OP  THE  UTERTTS,  '101 

of  the  axis  of  tlie  uterus,  and  in  less  than  half  a  minute,  succeed- 
ed completely  in  restoring;  it.  Mrs.  G had  not  an  unpleas- 
ant symptom  to  follow  this  accident. 

Case  Fourth, 

Mrs.  G was  delivered  on  the  24th  of  December,  ISOS,  at 

six  o'clock,  P.  M.,  after  a  labour  of  some  hours,  of  her  first  child. 
The  placenta  was  extracted  in  about  fifteen  minutes  without  force 
There  was  some  haemorrhage,  and  considerable  pain.  She  was  put 
to  bed,  and  became  very  faint,  and  complained  of  great  pain, 
which  was  occasionally  augmented.  She  continued  in  this  way, 
only  gradually  becoming  worse,  until  nine  o'clock,  at  which  time 
I  was  sent  for. 

I  found  her  with  a  small  frequent  pulse,  great  anxiety,  extreme- 
ly pale  and  cadaverous,  and  in  a  profuse  cold  sweat.  I  inquired 
respecting  the  flooding;  but  this  did  not  appear  to  be  sufficient  to 
account  for  her  present  situation.  I  immediately  suspected  a  par- 
tial inversion  of  the  uterus,  and  thought  proper  to  apprize  her 
friends  of  the  probable  cause  of  her  distress  and  danger,  and  of 
the  possible  result  of  it.  Everything  was  left  to  my  management. 
I  immediately  after  examined  her  per  vaginam,  and  found  my 
conjecture  true. 

The  uterus  was  found  inverted,  and  its  fundus  was  just  within 
the  OS  externum.  I  was  much  alarmed  for  the  patient,  as  three 
hours  and  more  had  elapsed  between  the  time  of  her  delivery  and 
my  being  called;  she  was  much  exhausted,  and  in  extreme  agony. 
I  quickly  introduced  my  left  hand  into  the  vagina,  and  applied  the 
back  of  my  fingers  firmly  against  the  tumour,  while  I  moderated  its 
influence  in  carrying  the  uterus  directly  up  through  the  pelvis,  by 
having  a  gentle  pressure  made  upon  the  abdomen  above  it.  The 
tumour  soon  began  to  yield,  and  in  about  two  minutes  the  fundus 
was  completely  restored. 

On  the  third  day  after,  my  patient  complained  of  a  severe  pain  in 
the  right  side  just  above  the  ilium,  for  which  I  bled  her  freely, 
and  purged  her  briskly.  Nothing  unpleasant  supervened;  she 
might  be  said  to  have  had  a  good  getting  up. 


492 
CHAPTER  XXXV. 

OF  TWINS,   &C. 

1327.  Under  this  head  I  shall  consider  pregnancies  composed 
of  two  or  more  children.  Twins  are  of  rare  occurrence;  so  much 
so  as  to  render  it  difficult  to  establish  the  proportion  between  them 
and  single  births;  especially  as  their  production  seems  to  be  go- 
verned by  contingencies  not  within  control,  or  altogether  inscru- 
table. Thus,  in  the  Middlesex  Hospital,  London,  there  was  but 
one  in  about  ninety-one,  while  in  Dublin  the  proportion  was 
greater.  In  France,  agreeably  to  one  return  of  "  I'Hospice  de  la 
Maternite,"  the  proportion  was  about  one  in  eighty-eight;  but, 
according  to  that  of  Madame  Boivin  of  the  same  institution,  the 
proportion  was  only  one  in  about  one  hundred  and  thirty  or  forty, 
while  in  that  of  the  "  Maison  d'Accouchemens,"  the  proportion 
was  about  one  in  ninety-one. 

1328.  In  this  country,  the  average  is  about  one  in  seventy-five. 
From  this  it  would  appear,  that  climate  or  the  state  of  civiliza- 
tion, agreeably  to  the  remark  of  Dr.  Denman,*  exerts  an  influence 
upon  the  multiplication  of  the  human  species;  and  that  where  the 
means  of  life  are  more  abundant  or  more  easily  procured,  the  pro- 
portion of  twins  is  probably  increased — this,  however,  is  by  no 
means  proved;  but  that  there  are  conditions  and  circumstances 
which  give  rise  to  more  double  births  in  this  country  is  certain,  if 
reliance  can  be  put  upon  the  various  tables  of  births. t  It  would 
be  a  curious  subject  of  inquiry  for  the  political  economist,  and  the 
physiologist,  to  ascertain  on  what  depends  the  frequency  of  plu- 
rality of  children. 

1329.  It  is  presumable  upon  general  principles,  that  whatever 
contributes  to  fecundity  in  any  country,  will  also  contribute  to 
the  production  of  twins,  &c.  since  a  certain  proportion  must  exist. 
We  have  just  said  that  the  power  of  reproduction  is  most  proba- 
bly influenced  by  the  facility  of  procuring  the  means  of  life;  this 
appears  to  be  the  case  from  the  investigation  of  M.  Benoiston,  as 
published  in  the  Revue  Medicale  for  December;  he  concludes 

*  System,  Francis's  ed.  p.  534. 

f  Francis's  ed.  of  Denman,  in  a  note,  pp.  613,  614.  Dr.  Arnell's  average 
is  one  in  seventy-five^  Dr.  Moore"s,  one  in  seventy-six. 


OF  TWINS,  &c.  493 

that  wherever  existence  is  easily  supported,  there  will  be  found 
an  abundance  of  children,  which  would  seem  to  procure  from 
the  same  causes  a  greater  proportion  of  twins,  &c. 

1330.  It  is  thought  by  many  women,  that  the  disposition  to 
double  births  is  hereditary;  and  some  facts  within  my  own  know- 
ledge seem  to  countenance  this  supposition,  but  they  are  by  no 
means  sufficiently  numerous,  or  sufficiently  strong  to  confirm  it. 
I  can  say,  however,  with  some  safety,  that  it  is  in  some  instances 
constitutional;  I  know  one  female,  who  has  had  five  twins  in 
succession,  and  had  not,  when  I  had  conversed  with  her  on  the 
subject,  (some  years  since,)  ever  had  a  single  birth.  I  knew 
another  who  had  twins  three  times,  but  not  immediately  follow- 
ing each  other. 

1331.  Where  I  to  decide  from  my  own  practice,  the  proportion 
of  twin  cases  would  be  greater  than  I  have  stated  above;  (1327) 
it  would  be  one  in  about  fifty  or  sixty — but  this  computation 
would  not  be  altogether  correct;  as  I  have  been  for  many  years, 
occasionally  called  to  the  aid  of  midwives  in  this  city,  among 
whose  cases  there  were  a  number  of  cases  of  twins — this  would 
increase  the  average  as  regards  my  own  practice,  without  giving 
a  just  view  of  their  frequency,  since  these  cases  should  be  con- 
sidered as  properly  belonging  to  the  averages  of  these  midwives. 

1332.  Triplets  are  very  much  more  rare — in  the  returns  of 
the  cases  in  the  "Maison  d'Accouchemens,"  as  furnished  by 
Baudelocque,  there  appears  to  have  been  but  one  in  more  than 
eight  thousand  cases;  in  the  return  of  Madame  Boivin  of  the 
cases  of  "  PHospice  de  la  JNIaternite,"  one  in  rather  less  than 
seven  thousand;  Dr.  Arnell,  one  in  twelve  hundred,  and  in  my 
own  practice,  in  more  than  ten  thousand  cases,  I  have  not  met 
with  an  instance  of  triplets.  Of  more  numerous  progeny,  the 
proportion  must  be  infinitely  small;  since  in  the  practice  of  the 
two  hospitals  above  mentioned,  in  the  private  practice  of  Drs. 
Arnell,  Woore,  and  myself,  amounting  in  all  to  more  than  fifty 
thousand  cases — there  is  no  mention  of  an  instance  of  four  chil- 
dren born  at  a  birth. 

1333.  We  are  farther  informed  by  Professor  Duges,  that  agree- 
ably to  the  register  of  "la  Maison  d'Accouchemens  de  Paris," 
for  twenty  years,  the  following  proportion  of  twins  and  triplets 
were  registered. 

In  37,441  deliveries,  there  were  36,992  single  births;  444 
twins;  5  triplets;  but  no  instance  of  more  numerous  progeny 


494  or  TWINS,  &c. 

was  observed,  either  in  "I'Hospice  de  la  Maternite,"  at  least 
up  to  the  year  1821,  nor  in  the  Hotel  Dieu,  before  the  estaljlish- 
ment  of  tlie  maternity,  for  sixty  years  previous  to  the  year  1821; 
though  the  total  amount  of  cases  in  these  institutions,  amounted 
to  108,000. 

1334.  But  he  adds,  that  "instances  of  quadrigeminii  have  oc- 
casionally been  met  with.  Lately  the  journals  have  announced 
a  case  of  this  kind;  and  a  similar  instance  occurred  in  Paris,  in 
October,  1823,-  and  Gottleib  mentions  a  case  of  a  woman  at  Stras- 
burg,  who  had  eleven  children  at  three  deliveries,  of  course  making 
a  recurrence  of  quadrigemini  twice,  and  of  triplets  once."* 

1335.  In  this  country,  it  is  not  very  unusual  to  find  announced 
in  our  public  prints,  instances  of  four  children;  it  may  however 
be  questioned,  whether  such  are  as  frequent,  as  such  proclama- 
tions declare.  We  however  find,  in  the  Albany  Argus,  the  fol- 
lowing account  of, ''  unparalleled  fecundity."  Dr.  0.  F.  Paddock, 
a  respectable  physician  of  Fort  Covington,  Franklin  county,  gives, 
in  the  Franklin  Telegraph,  an  account  of  an  extraordinary  birth 
oijive  children  at  one  time  from  the  same  mother — three  daugh- 
ters and  two  sons.  Four  of  them  were  born  alive,  but  lived  a 
short  time.  The  birth  was  premature  three  months,  but  they 
were  perfectly  well-formed  and  well-shaped.  The  average  weight 
was  about  two  pounds,  and  not  much  difierence  in  their  size. 
Their  parents  lately  emigrated  from  Ireland,  and  arrived  in  this 
country  in  August  last.  This  is  rendered  more  remarkable  by 
the  fact  that  the  mother  of  these  five,  was  delivered  on  the  20th 
of  last  February  of  two — making  in  the  whole,  seven  children  in 
less  than  nine  months.  The  last  were  born  on  the  25th  Novem- 
ber, 1826.  <'  Dr.  Ryan,  the  learned  Editor  of  the  London  Medi- 
cal and  Stirgical  Journal,  states  that  he  was  called  to  a  patient, 
aged  forty-one,  of  a  sanguine  temperament,  who  had  menstruated 
at  the  age  of  twelve,  and  married  between  eighteen  and  nineteen. 
She  had  a  seventh  month's  child  in  tlie  eighth  month  of  her  mar- 
riage— had  twins  about  the  fourth  month  three  times  during  the 
year  1829,  and  again  December  31,  when  she  was  attended  by 
Mr.  Whitemore,  of  Cold  bath  Fields,  and  delivered  of  two  infants; 
and  on  January  2Sth,  1830,  she  was  attended  by  Mr.  Thomas,  of 
Bagnigge  Wells  Road,  and  delivered  of  an  infant,  which  he  con- 
sidered of  the  same  age  as  the  preceding.     On  the  7th  of  June 

*  Kevuc  Modicale,  toni.  1.  p.  340. 


OF  TWINS,  &c.  495 

last,  (1830)  she  aborted  at  the  third  month;  and  on  the  9th,  a 
second  foetus  was  expelled;  she  was  attended  by  Mr.  Sandell; 
and  as  there  was  no  discharge  whatever  from  that  time  to  this, 
considers  herself  still  pregnant.  The  abdomen  is  about  the  size 
of  a  woman  in  the  fifth  month  of  utero-gestation;  she  has  had 
twenty-four  children  in  twenty-one  years.  She  menstruated  re- 
gularly before  marriage.  She  is  always  in  good  health  when 
suckling,  and  ill  when  breeding:  she  always  becomes  pregnant 
about  the  fifth  month  of  lactation.  Her  mother  is  seventy  years 
of  age,  and  is  in  good  health;  she  has  had  eighteen  childrenTaorn 
alive.  A  relation  of  her  husband  has  had  thirty-two  children 
including  miscarriages."  Amer.  Jour,  of  Med.  Sciences,  for  Feb. 
1831.  The  author  has  lately  conversed  with  a  lady,  who  was 
then  in  her  thirty-eighth  year,  who  declared  to  him  that  she  had 
been  pregnant  two  and  thirty  times;  of  this  number  eleven  were 
born  alive  and  at  the  full  time.  She  repeatedly  miscarried  of 
twins,  and  no  abortion  was  less  than  near  three  months — she  had 
been  married  nearly  twenty-three  years. 

1336.  The  case  (1335)  is  styled  "unparalleledj"  but  Dr.  Duges 
states,  that  there  is  a  case  mentioned,*  on  the  authority  of  Petre- 
tein,  a  Greek  Physician,  in  which  the  woman  was  delivered  pre- 
maturely, (seventh  month,)  of  three  living  females,  and  one  dead, 
and'one  boy,  all  equally  well  developed. t 

1337.  Women  who  are  more  than  ordinarily  large,  are  apt  to 
suspect  themselves  pregnant  with  twins,  and  on  this  account  much 
anxiety  is  always  expressed.  The  accoucheur  is  not  unfrequently 
consulted,  and  his  opinion  requested,  on  this  momentous  subject, 
so  soon  as  this  fear  is  excited;  but  much  caution  should  be  used 
in  answering  this  question;  indeed  it  should  always  be  resolved 
in  the  negative,  and  for  two  reasons  especially;  first,  because  it 
is  impossible  to  decide  it  positively;  and  secondly,  if  it  could  be, 
it  never  should  be,  as  much  mischief  might  arise  from  the  uneasi- 
ness it  might  produce. 

1338.  We  have  no  certain  marks  before  labour  by  which  we 
can  determine  there  is  more  than  one  child  in  the  uterus;  a  num- 
ber of  signs:]:  are  recorded,  purporting  to  declare  this  condition, 

*  Biblioth.  Med.  torn.  19.  p.  374. 

f  Revue  Med.  loc.  cit. 

+  'I'he  ciuimcnited  signs  which  purport  to  decide  the  woman  to  be  pregnant 
of  twins,  are — 1st.  The  extraordinary  size  of  the  abdomen  of  the  woman.  2d. 
The  division  of  the  abdomen  into  tumours  upon  its  anterior  surface,  occasioned 


496  OP  TWINS,  &c. 

but  not  one  of  which  can  be  positively  depended  on.  Baudelocque 
and  Denman  say  the  same  thing;  the  former  is  of  opinion  that  the 
union  of  all  these  signs  sometimes  gives  strong  presumption  of 
the  existence  of  twins,  but  that  "touching  alone  can  dissipate  our 
doubts,  and  that  only  at  the  last  months  of  pregnancy."  "  For," 
says  he,  "  when  the  belly  is  so  large  as  to  give  the  suspicion  of 
two  children,  if  there  is  but  one,  it  is  always  very  moveable,  be- 
cause it  is  then  in  a  large  quantity  of  water:  we  easily  move  it 
by  means  of  the  finger  introduced  into  the  vagina,  and  its  rolling 
is  n^ver  more  manifest  than  when  we  do  that.  When  there  are 
two,  that  movement  is  scarcely  sensible;  \vc  easily  distinguish 
that  the  child  we  endeavour  to  move  by  touching,  is  surrounded 
by  only  a  little  fluid,  and  that  it  is  encumbered  by  another  solid 
body;  if  we  apply  the  hand  on  the  women's  belly  in  one  of  these 
movements,  when  the  parietes  of  the  uterus  are  supple,  and  as  it 
were,  slackened,  we  may  discover  these  children  as  clearly  as  in 
other  cases  we  distinguish  the  feet,  the  knees,  or  the  arm  of  that 
which  is  single."* 

1339.  The  whole  of  the  information  we  can  gain,  either  by 
taking  into  consideration  the  enumerated  signs,  or  by  touching  as 
proposed  by  Baudelocque,  can  never  amount  to  more  than  pre- 
sumptive evidence;  as  the  whole  of  the  signs  have  been  known 
to  exist  without  the  woman  being  pregnant  of  twins.  And*  the 
quantity  of  liquor  amnii  difiers  from  a  few  ounces  to  several 
pounds  in  even  single  pregnancies;  therefore,  no  certain  conclu- 
sion can  be  drawn  from  the  mobility  or  immobility  of  the  foetus 
in  utero. 

1340.  Dr.  Duges  says,  "  the  most  unequivocal  sign  of  the  ex- 
istence of  twins,  is  the  presence  of  two  pouches  of  water  at  the 
orifice  of  the  uterus.  He  says  he  has  met  with  this  circumstance; 
so  also  does  Madame  La  Chapelle.  One  of  these  pouches  may  be 
more  round  than  the  other  and  contain  some  portion  of  the  foetus; 
the  other  is  flattened  and  curved,  (courbee,)  and  for  the  most 
part  contains  only  the  liquor  amnii. "t  I  have  never  met  with 
such  an  instance;  nor  do  I  recollect  it  having  been  mentioned  be- 
fore. 

by  the  unequal  stretcliing'  of  the  recti  muscles.  3d.  An  ocdematous  condition 
of  the  inferior  extremities,  after  the  tiilrd  or  fourth  month;  and,  4th.  The  vari- 
ous or  numerous  places  at  which  the  woman  feels  motions  or  stirrings. 

•  System,  vol.  111.  ]>.  442. 

f  Revue  Med.  loc.  cit. 


OF   TWINS,  &c.  497 

1341.  The  uncertainty  whether  a  woman  be  pregnant  of  one 
or  more  children,  fortunately  is  of  no  consequence,  until  the  la- 
bour has  positively  commenced;  for,  previously  to  this  time,  our 
conduct  in  every  respect  should  be  the  same,  as  if  there  were  but 
one  child.  But  at  this  period  it  would  in  many  instances  be  ex- 
tremely useful,  when  the  children  were  offering  untowardly ;  as 
the  cause  of  difficulty  would  then  be  ascertained,  and  the  indica- 
tions fairly  declared.  In  cases  of  twins,  the  situation  of  the  chil- 
dren, either  as  regards  themselves,  or  the  pelvis,  may  be  more 
or  less  favourable,  and  consequently,  complicate  the  labour  in 
proportion. 

1342.  The  situation  of  twins  or  triplets  may  be  such  as  regards 
each  other,  as  to  offer  almost  insuperal  difficulties  to  delivery. 
Such  was  the  case,  in  the  history  of  a  twin  labour,  given  by  Dr. 
Erwin;  the  head  of  one  fajtus  was  placed  so  closely  over  the  neck 
of  the  one  which  presented  the  breech  and  was  delivered  all  but 
the  head,  that  this  part  could  not  be  made  to  descend  by  any 
force,  or  ingenuity,  that  this  physician  could  employ.  The  crotchet 
was  resolved  on  and  used;  after  this,  by  great  exertion,  the  head 
was  extracted;  but  to  the  surprise  of  the  gentleman,  it  was 
uninjured  by  the  crotchet.  This  pointed  out  the  situation  of  the 
heads  of  the  children  as  stated  above. 

1343.  Dr.  Clough*  also  met  with  an  instance,  in  which  great 
difficulty  was  experienced,  but  not  equal  to  the  one  related  by 
Dr.  Erwin;  such  cases  bid  defiance  to  rules:  everything  must  be 
left  to  the  good  sense  and  discretion  of  the  practitioner. 

1344.  Twins  may,  first,  be  enclosed  in  one  common  covering 
of  membranes,  and  inhabit  the  same  nidus,  and  float  in  the  same 
waters;  second,  they  may  each  have  a  separate  amnion,  while 
the^horion  may  be  common  to  both;  third,  each  may  have  its 
own  membranes,  waters,  and  placenta. 

1345.  The  different  siluation  in  which  twin  children  may  be 
placed  while  in  utero,  especially  the  two  first,  (1344)  disturb 
every  projected  scheme,  with  respect  to  impregnation;  they  un- 
settle that  which  has  been  hitherto  thought  pretty  well  proved, 
as  regards  the  ovaries,  the  fecundation  of  ova,  and  the  absolute 
nature  of  the  ovum  itself;  and  throw  into  confusion  that  which 
has  been  thought  clear;  or,  they  oblige  us  to  extend  our  notions 

*  Lond.  Med.  Journ.  vol.  25. 
63 


498  OF  TWINS,  &c. 

of  the  powers  of  the  corpora  lulea,  very  much  beyond  what  they 
have  hitherto  been. 

1346.  They  disturb  (1344)  all  the  schemes  for  impregnation, 
since  they  all  suppose,  that  each  ovum  is  a  separate  and  distinct 
germ,  and  included  in  distinct  coverings;  yet  two  are  found  in- 
volved in  the  same  common  covering  with  two  umbilical  cords, 
and  with  one  placenta.  It  unsettles  that  which  has  been  thought 
pretty  well  confirmed  as  regards  the  ovaries,  to  wit:  that  they 
furnish  ova  for  impregnation,  upon  different  portions  of  its  sur- 
face, yet  two  embryons  are  found  to  bathe  in  the  same  waters, 
and  with  one  placenta  for  their  support;  providing,  it  would  seem, 
that  an  ovum  may  contain  more  than  one  germ,  which  may  be 
fecundated  at  one  and  the  same  time.  They  throw  into  confusion 
that,  v/hich  has,  especially  of  late,  been  thought  perfectly  clear 
and  well  understood,  as  follows:  that  the  corpora  lutea  furnish 
the  ova  for  impregnation;  that  each  corpus  luteum  yields  its  own 
oyum,  and  that  each  ovum  brings  with  it,  from  its  nidus,  its  own 
chorion  and  amnion;  yet  they  are  both  found  common  to  two 
children  ;  or  the  chorion  alone  common,  and  each  has  its  amnion; 
yet  with  distinct  cords  and  a  placenta  in  common — now  I  would 
ask,  how  this  can  be,  agreeably  to  our  present  notions  of  impreg- 
nation? Does  it  not  oblige  us  to  extend  the  powers  of  a  corpus 
luteum,  and  make  us  admit,  that  one  ovum  may  contain  the  ru- 
diments of  two  foetuses,  or  oblige  us  to  call  in  question  the  ar- 
rangements just  spoken  of?*  (1345) 

1347.  The  third  situation  of  foetuses  in  utero  (1344)  proves, 
that  two  ova  may  furnish  embryos  with  their  own  coverings, 
since  they  exist  separately  and  distinctly  in  some  cases  of  twins: 
and  their  separate  existence  renders  it  more  than  probable  that 
they  were  the  product  of  different  ova,  and  as  probable  that  tach 
issued  from  a  separate  ovarium.  For,  if  we  do  not  admit  this, 
we  must  allow  that,  which  not  only  wants  proof,  or  even  pro- 
bability, and  ver}''  much  more  difficult  to  reconcile;  name- 
ly,   that   a   fallopian    tube    can    successfully    transmit   two   ova 

*  May  we  not  reasonably  doubt,  that  two  children  can  float  in  the  same  wa- 
ters as  an  original  disposition  of  them?  May  we  not  suppose  that  the  muscular 
exertions  of  the  children  may  have  broken  the  separating  membranes,  and  thus 
permitted  the  waters  to  unite?  For  it  cannot  be  doubted,  that  they  have  been 
found  together:  as  Dr.  Denman  (Francis's  ed.  p.  541,)  tells  us,  his  fi-iend.  Dr. 
Sims,  informed  him  of  a  case  of  twins,  where  the  funes  were  so  closely  twined 
together,  as  to  appear  but  one. 


OP  TWINS. 


&c.  499 


at  one  and  the  same  time,  or  consecutively;  which,  agreeably  to 
all  the  present  known  schemes  of  the  ovum  getting  possession  of 
the  uterus,  would  be  very  difficult  to  reconcile,  though  not  per- 
haps, impossible;  but  by  admitting  a  simultaneous  action  in  the 
tubes,  and  each  ovarium  furnishing  an  ovum,  the  explanation  is 
easy;  therefore  to  be  preferred.     But  a  truce  with  speculation. 

1348.  The  labour  of  a  woman  pregnant  with  twins,  begins  in 
every  respect  like  a  labour  in  which  there  is  but  one;  but  its  pro- 
gress in  general  is  neither  so  regular  nor  so  rapid.  The  latter 
circumstance  is  not  difficult  to  explain;  since  it  is  impossible  that 
either  child  can  receive  the  undivided  influence  of  the  contract- 
ing uterus,  and  therefore,  it  cannot  be  so  rapidly  expelled;  or 
they  may  be  so  situated  as  to  impede,  if  not  to  oppose,  each 
other's  exit;  hence,  the  labour  is  slower,  at  least  with  the  deli- 
very of  the  first  of  the  children;  but  with  the  second  it  may  be 
quicker,  nay,  even  rapid.  This  being  the  case,  if  we  could  even 
determine  before  hand,  that  the  labour  is  a  twin  case,  we  should 
not  alter  our  conduct,  except  there  be  something  in  the  labour 
itself,  which  would  require  interference,  independently  of  its  be- 
ing a  compound  pregnancy. 

1349.  In  general,  nay  almost  always,  we  do  not  know  we  are 
encountering  a  twin  case,  until  after  the  birth  of  the  first  child; 
we  may  then  suspect  this  to  be  the  case;  1st.  When  the  child  is 
small,  compared  with  the  size  of  the  abdomen  of  the  mother,  and 
the  quantity  of  water  discharged;  2d.  If  the  abdominal  tumour 
have  not  subsided  as  much  as  if  it  were  a  single  child ;  3d.  Because 
the  child  may  be  felt  through  the  abdominal  and  uterine  parietes; 
4th.  Because  there  is,  in  general,  a  renewal  of  uterine  contrac- 
tions, and  the  child  can  be  felt  per  vaginum,  if  its  membranes 
have  given  way,  or  the  membranes  themselves  when  distended 
with  the  waters  if  they  are  entire. 

1350.  After  the  birth  of  the  first  child,  and  we  have  ascertain- 
ed that  there  is  a  second,  it  then  becomes  a  question,  what  is  to 
be  done  with  the  second?  Accoucheurs  seem  to  have  puzzled 
themselves  in  answering  this  plain  and  simple  question,  and  have 
attempted  to  lay  down  rules,  which  are  calculated  to  embarrass, 
rather  than  instruct,  the  inexperienced  practitioner.  The  rule 
upon  this  subject  is  plain,  and  void  of  all  ambiguity,  since  it  is 
founded  upon  the  disposition  and  situation  of  the  uterus  itself. 
Baudelocque  alone  is  rational  on  this  subject. 

1351.  I  have  said  the  rules  of  practice  in  cases  of  twins,  after 


500  OF  TWINS,  &C. 

the  birth  of  the  first  child,  were  free  from  all  difficulty  or  ambi- 
guity; for  after  one  child  is  expelled,  one  of  two  things  must  hap- 
pen, either  that  pains  will  pretty  quickly  ensue,  and  deliver  the 
second  if  its  position  be  natural,  or  that  there  will  be  a  suspension 
of  pain. 

1352.  If  the  first  case  obtain,  we  must  conduct  the  labour,  as 
if  it  were  an  original  labour,  and  not  to  be  interfered  with  so  long 
as  there  is  a  rational  expectation  that  nature  is  competent  to 
relieve  herself;  and  if  this  promise  be  not  made,  or  seasonably 
fulfilled,  we  must  interfere  as  upon  any  other  occasion,  where 
interference  might  be  necessary.  When  pains  follow  the  expul- 
sion of  the  first  child,  there  is  every  expectation  they  will  accom- 
plish the  delivery  of  the  second;  first,  because  it  will  receive  the 
whole  influence  of  the  uterus,  which  was  divided  before;  second, 
because  the  subsequent  pains  will  be  more  powerful  than  the 
antecedent  ones;  since  the  uterus  is  now  smaller,  and  its  tonic 
contraction  more  perfect,  which,  (cseteris  paribus,)  always  in- 
creases the  alternate  contractions  of  this  organ;  third,  because 
the  parts  have  been  dilated,  and  are  of  course  made  to  yield 
by  the  passage  of  the  first  child ;  therefore  thepe  is  less  resistance 
to  be  overcome. 

1353.  If  the  second  situation,  namely,  where  there  is  a  suspen- 
sion of  pain,  our  duty  is  equally  clear — for  it  will  depend  altoge- 
ther upon  the  situation  of  the  uterus  itself.  This  condition  will 
consist  in  its  being  uncontracted  or  contracted. 

1354.  If  in  the  first  condition,  it  will  be  attended  with  hsemor- 
rhage,*  or  be  free  from  it — if  with  flooding,  we  are  to  deliver  as 
we  would  in  any  other  case  of  haemorrhage,  and  be  regulated  by 
the  same  rules  which  govern  upon  such  occasions;  if  no  haimor- 
rhage  be  present,  we  must  solicit  the  contraction  of  the  uterugby 
frictions  upon  the  abdomen,  until  it  contract.  If  it  be  contracted, 
and  pains  do  not  pretty  soon  follow,  I  have  long  thought  it  best 
to  make  the  labour  an  artificial  one,  and  for  the  foUov/ing  rea- 
sons.! 

1355.  First,  because  if  pains  do  not  come  on  in  the  course  of  a 
half  hour  after  the  tonic  contraction  of  the  uterus  is  well  esta- 
blished, it  is  altogether  uncertain  when  they  will  take  place;  and 

•  The  same  may  be  said  of  eitlier  of  the  other  accidents  that  may  complicate 
a  labour.  (651) 

f  I  believe  it  would  be  a  good  general  rule  of  practice,  when  the  contractions 
are  feeble,  or  very  far  apart,  to  administer  the  ergot. 


OF  TWINS,  &0.  501 

the  patient  is  then  left  in  great  anxiety  for  the  event;  second 
after  the  expulsion  of  the  first  child,  a  haemorrhage  or  other  acci- 
dent may  ensue  which  will  oblige  us  to  deliver  under  all  the  em- 
barrassments it  gives  rise  to;  third,  there  is  nothing  to  apprehend 
in  terminating  the  labour,  as  the  tonic  contraction  is  secured;  and 
no  difficulty  can  be  created,  since  the  uterus  will  readily  permit 
turning,  if  the  head  present;  or  to  deliver,  as  directed  when  either 
the  breech,  feet,  or  knees  present,  when  there  is  a  necessity  of 
making  an  artificial  labour  of  the  case;  fourth,  we  remove  at  once 
the  anxiety  of  the  woman;  which,  if  long  continued,  may  have  a 
very  unfriendly  influence  upon  the  powers  of  the  uterus. 

1356.  All  rules  of  conduct,  taken  from  the  lapse  of  time,  are 
liable  to  very  serious  objections;  for  mere  waiting  does  not  insure 
the  proper  condition  of  the  uterus  to  render  our  acting  safe;  and 
we  are  never  to  proceed  to  delivery  if  that  proper  condition,  (1201, 
1202)  does  not  follow^  however  long  we  may  have  waited,  for,  at 
the  end  of  four  hours,  (Dr.  Denman's*  rule,)  it  may  be  just  as  im- 
proper to  deliver,  as  it  may  have  been  at  fifteen  minutes  after  the 
birth  of  the  other  child;  and  if  contraction  justifies  us  to  deliver 
at  the  end  of  four  hours,  it  justifies  us  at  any  intermediate  period  at 
which  it  may  take  place.  And  if  we  are  to  act  at  the  end  of  four 
hours  be  the  condition  of  the  uterus  what  it  may  (for  nothing  is 
said  of  the  state  of  this  organ),  we  shall  as  certainly  do  mischief  by 
our  interference  if  the  uterus  be  not  contracted,  as  if  we  had 
acted  at  any  other  antecedent  period.  If  then  we  do  not  insure 
the  contraction  of  the  uterus  by  waiting,  we  gain  nothing;  and  it 
will  be  proper,  therefore,  to  act  whenever  we  are  assured,  that 
the  powers  of  the  uterus  are  in  full  and  healthy  play,  be  this 
when  it  may. 

1357.  Should  any  of  the  enumerated  accidents  (651)  compli- 
cate a  labour  of  twins,  we  must  act  as  in  any  other  case;  taking 
care  at  the  time,  to  distinguish  tlie  proper  feet,  when  we  are  about 
to  bring  them  down,  and  when  both  sets  of  membranes  are  rup- 
tured: but  if  they  are  not,  and  we  discover  it  to  be  a  twin  case  in 
proper  time  after  we  have  commenced  the  operation,  to  be  care- 
ful not  to  rupture  the  membranes  of  the  remaining  child.  If  the 
breech,  feet,  or  knees  ofier,  we  must  bring  down  the  feet,  or  act 
upon  them,  as  has  been  directed — or  if  the  head  present,  and 
the  labour  be  far  advanced,  we  must  use  the  foiecps,  though 

*  Introduction,  Francis's  ed.  p.  540. 


502  OF  TWINS,  &c. 

we  are  certain  it  be  a  twin  case.  Or  should  any  thing  untoward 
take  place  during  the  transit  of  the  second  child,  we  must  act  as 
the  nature  of  the  case  requires,  without  reference  to  its  being  a 
twin. 

1358.  In  my  estimation,  Mr.  Burns*  lays  down  two  very  doubt- 
ful rules  for  the  management  of  twin  cases — the  first  is,  that  "  if 
effective  pains  do  not  come  on  in  a  quarter  of  an  hour,  the  child 
ought  to  be  delivered  by  turning."  The  second  is,  "  if  the  posi- 
tion of  the  second  child  be  such  as  to  require  turning,  we  are  to 
lose  no  time,  but  introduce  the  hand  for  that  purpose  before  the 
liquor  amnii  be  evacuated,  or  the  uterus  begin  to  act  strongly 
071  the  childy 

1359.  If  we  were  to  act  agreeably  to  these  directions,  we 
should  almost  constantly  have  cause  to  repent  the  enterprize;  for 
we  certainly  should  do  mischief  by  exposing  the  uterus  to  a 
state  of  atony;  and  thus  provoke,  perhaps,  a  fatal  hsemorrhage. 
I  must  repeat,  in  such  cases,  we  should  pay  no  regard  to  the  time 
which  may  elapse  after  the  birth  of  the  first  child;  it  Ts  to  the 
condition  of  the  uterus  alone  we  should  direct  our  attention,  and 
that  alone  should  regulate  our  conduct.  For,  if  the  uterus  be  well 
contracted,  we  may  act  at  any  period  it  may  be  necessary,  with 
perfect  safety;  but  if  it  be  not,  nothing  can  justify  the  interfer- 
ence, save,  that  the  patient  may  be  attacked  by  one  of  the  acci- 
dents enumerated  above.  (651) 

a.  On  the  management  of  the  Placenta. 

1360.  From  what  has  been  said  above,  (1344,  &c.)  it  will  not 
always  be  found  that  each  child  in  twin  cases  will  have  its  pla- 
centa; yet  it  is  generally  the  case  ;  and  though  only  connected  by 
interposing  membrane,  we  are  obliged  to  deliver  them  together. 
Before,  however,  we  make  the  attempt  to  deliver  the  placenta, 
when  have  reason  to  suspect  there  is  another  child:  or  when 
this  has  been  ascertained,  we  should  apply  two  ligatures  upon  the 
funis  of  the  delivered  child,  and  cut  between  them;  as  the  cut 
extremity  in  such  cases  yields  a  good  deal  of  blood  sometimes; 
and  occasionally  it  is  said,  even  to  the  exhaustion  of  the  second 
child.  We  should  never  attempt  to  deliver  the  placenta  in  twin 
cases,  until  both  children  are  born. 

1361.  This  bleeding  may  happen  where  both  funes  belong  to 

*  Principles,  James's  ed.  p.  406. 


OF  TWINS,  &c.  503 

one  placenta,  or  where  the  two  children  are  supplied  by  one  ori- 
ginal cord,  branching  some  distance  from  the  placenta  to  furnish  a 
funis  to  each — and,  as  we  cannot  beforehand  ascertain  such  devi- 
ations, it  is  best  to  guard  against  the  chance  of  mischief  by  the  ap- 
plication of  a  ligature;  this  may  bo  removed  after  the  birth  of  the 
second  child,  that  it  may  discharge  some  of  the  blood  contained  in 
the  placenta,  for  the  reasons  before  stated.   (554) 

1362.  The  delivery  of  the  placentse  of  twins  must  be  conduct- 
ed upon  the  same  general  principles  as  if  there  were  but  one — 
but  rather  more  time  should  be  given,  and  caution  exercised  in 
twin  cases;  because,  the  uterus  has  been  more  distended  during 
gestation,  and  more  severely  exercised  sometimes  during  parturi- 
tion with  a  single  birth:  consequently,  the  tonic  contraction 
will  be  more  slowly  and  reluctantly  performed,  and  the.  woman 
more  exposed  to  flooding.  Brisk  frictions  should  be  immediately 
instituted,  and  sufficiently  persevered  in,  to  insure  the  object  for 
which  they  were  employed. 

1363.  When  the  tonic  contraction  of  the  uterus  is  confirmed, 
we  may  then,  and  never  until  then,  proceed  to  the  delivery  of  the 
placentae — they  will  be  found  either  occupying  the  vagina,  or  be 
beyond  the  reach  of  the  finger.  If  in  the  first  situation,  they  may 
be  extracted  by  a  small  force  exerted  upon  the  cords,  and  the 
aid  of  a  finger  introduced  into  the  vagina.  If  in  the  second  we 
must  co-operate  with  the  uterine  contractions  when  they  exist,  by 
pulling  gently,  but  pretty  firmly,  by  the  cords,  but  not  with  equal 
force  on  each — if  we  do,  we  tend  to  bring  both  placentae  at  the 
same  time  to  the  os  uteri;  and  their  united  bulks,  will  not  readily 
pass  it— we  should  therefore  act  more  firmly  upon  the  cord  first 
out,  as  it  is  more  than  probable  its  placenta  is  nearest  the  uterine 
orifice,  and  will  more  easily  descend,  and  at  the  same  time,  brino- 
the. other  with  it. 

1364.  Should  there  be  no  pain  to  aid  in  the  expulsion  of  the 
placentse,  we  must  continue  the  abdominal  frictions,  and  act  occa- 
sionally upon  the  cords,  by  applying  rather  more  force  upon  the 
first,  than  upon  the  second,  for  reason  just  stated.  (1363)  A 
slight  dischai-ge  of  fluid  blood,  or  small  coagula,  almost  always  an- 
nounces the  descent  of  the  placenta;  this  is  equally  observed  when 
there  are  two;  and  when  we  find  this  taking  place,  we  must  con- 
tinue a  gentle  tractive  effort,  until  they  are  lodged  in  the  vagina 

from  this  they  must  be  withdrawn  as  already  intimated.  (1363) 


504  OP  TWINS,  &c. 

1365.  Dr.  Denman  says,*  "when  the  placentae  are  separate, 
that  of  the  child  should  not  be  extracted  before  the  birth  of 
the  second  child,  as  a  discharge  of  blood  must  necessarily  follow, 
and  perhaps  a  haemorrhage."  This  certainly  would  be  rational 
advice,  and  highly  useful,  were  we  informed,  how  we  are  to 
know  beforehand,  when  the  placentae  exist  separately.  I  have  al- 
ready directed,  (1363)  that  the  first  placenta  is  not  to  be  meddled 
with,  in  twin  cases,  until  the  second  is  ready  for  delivery,  and 
with  this  direction  I  believe  we  must  rest  satisfied;  and  without 
ascertaining  whether  it  be  separate  or  connected. 

1366.  Dr.  Denman  farther  says, "  if  there  have  been  a  necessi- 
ty of  extracting  the  children  by  art,  it  is  comTnonly,  but  not  uni- 
versally, necessary  to  extract  the  placentas  also  by  art;  but  if  the 
placentae  are  detained  beyond  a  proper  time,  we  will  say  two 
hours^  after  the  birth  of  the  second  child,  it  is  desirable,  though 
there  may  be  no  very  urgent  symptoms,  that  we  should  inform 
ourselves  of  the  cause  of  this  distention,  and  act  accordingly. 

1367.  The  first  of  these  remarks,  namely,  that  the  interference 
of  art  is  necessary  to  the  delivery  of  the  placentae,  if  it  has  been 
necessary  for  that  of  the  children,  is  by  no  means  agreeable  to 
my  experience;  nor  do  I  see  the  slightest  relation  between  these 
events;  and  if  acted  upon  by  inexperienced  practitioners,  as  it 
certainly  will  be,  when  advised  by  such  high  authority  much 
mischief  will  ensue.  And  to  the  second,  I  must  again  object,  as  the 
rule  is  taken  from  time;  which  can  never  in  itself  constitute  -a 
reason,  nor  develope  a  principle;  for,  as  I  have  upon  another  oc- 
casion remarked,  it  may  be  just  as  improper  at  the  end  of  two 
hours  to  deliver  the  placentae  as  it  was  immediately  after  the  de- 
livery of  the  last  child. 

1368.  If  artificial  means  be  resorted  to,  care  should  be  taken 
that  both  placentae  are  detached  from  the  uterus,whether  they  exist 
separately,  or  if  they  be  merely  joined  by  membrane;  if  there  be 
but  a  placenta,  it  must  be  removed,  as  upon  common  occasions. 

1369.  In  cases  of  twins,  a  much  larger  surface  is  occupied  by 
the  placentae  than  if  there  were  but  one;  we  should  on  this  ac- 
count be  very  careful  to  renew  the  frictions  upon  the  abdomen, 
after  their  expulsion,  that  the  uterus  may  contract  as  much  as 
possible;  and  thus  tend  to  diminish  the  subsequent  discharges, 
which  are  but  too  apt  to  be  in  excess. 

*  Francis's  edition,  p.  541, 


505 
CHAPTER  XXXVI. 

OF  PRETERNATURAL  LABOURS. 

1370.  Agreeably  to  the  classification  I  have  adopted  for  la- 
bours, it  will  be  at  once  understood,  that  the  class  termed  pre- 
ternatural, will  consist  of  all  such,  as  shall  not  present  either  the 
head,  the  breech,  the  feet,  or  the  knees.  Authors  have  made  a 
very  numerous  collection  of  preternatural  labours:  some  of  which 
occur  so  rarely,  as  to  be  seldom,  or  perhaps  never  met  with,  even 
by  an  old  and  experienced  practitioner. 

1371.  Baudelocque  has  been  too  lavish  in  his  divisions,  and 
subdivisions  of  this  class  of  labours;  for  they  serve  rather  to  con- 
fuse, than  to  elucidate.  To  the  inexperienced  practitioner,  his 
distinctions  are  appalling;  for,  they  cannot  Avell  be  retained  in 
the  memory;  consequently,  his  rules  cannot  always  be  acted  upon. 
But  little  injury  can  arise  from  this  want  of  memory;  provided, 
the  general  principles  which  are  to  govern  in  such  cases  be  re- 
collected; for  they  are  all  to  be  treated  by  "  turning."*  If,  then, 
the  principles  laid  down  for  this  operation  be  well  recollected, 
little  or  no  embarrassment  can  present  itself. 

1372.  It  may,  however,  not  be  amiss  to  remind  the  inexpe- 
rienced practitioner,  of  several  of  the  most  important  rules  upon 
the  operation  of"  turning." 

1373.  1st.  This  operation  must  never  be  attempted  so  long  as 
the  OS  uteri  is  not  dilated  or  easily  dilatable. 

1374.  2d.  That  the  woman  must  be  placed  upon  her  back,  that 
the  utmost  freedom  may  be  given  to  the  operator's  hands. 

1375.  3d.  That  the  time  for  the  introduction  of  the  hand  into 
the  vagina,  is  during  a  pain,  after  having  been  well  lubricated. 

1376.  4th.  But  after  the  hand  is  in  the  uterus,  every  attempt 
to  turn  must  be  made  in  the  absence  of  pain. 

1377.  5th.  That  it  is  rarely  a  matter  of  indifference,  which 
hand  is  to  be  employed  for  the  pui-pose  of  turning;  therefore, 
the  rule  upon  this  subject  must  never  be  violated. 

•  Except  such  cases  .is  leave  no  doubt  of  tlie  death  of  the  child,  and  which 
inay  be  terminated,  by  the  crotchet. 
64 


506       PRESENTATION  OF  THE  ARM  AND  SHOULDER. 

1378.  6th.  That  whatever  be  the  situation  of  the  child  within 
the  uterus,  the  feet  must  be  brought  into  the  pelvis,  so  as  to  bend 
the  body  forwards.     See  Chapter  on  "Turning." 

1379.  I  shall  however,  treat  of  one  case  of  '<  preternatural  la- 
bour," from  the  general  class;  because,  it  is  by  far  the  most  fre^ 
quent,  as  well  as  the  most  difficult — this  case  is  the  "presenta- 
tion of  the  arm  and  shoulder. " 


CHAPTER  XXXVII. 

OF  THE  PRESENTATION  OF  THE  ARM  AND  SHOULDER. 

1380.  Should  the  hand  descend  into  the  pelvis,  either  by  not 
keeping  it  up  as  directed,  (716)  when  it  accompanies  the  head, 
or  any  other  part;  or  when  it  seems  to  fall  into  that  cavity  at  the 
time  the  membranes  give  way,  it  will  almost  always  become  a 
source  of  trouble;  especially,  if  under  the  care  of  a  practitioner, 
who  supposes,  he  cannot  do  better  than  to  act  upon  it,  to  effect 
delivery.  When  the  hand  is  not  supported,  so  as  to  allow  the 
head  to  descend  without  it,  the  arm  is  almost  sure  to  come  into 
the  passage:  this  frequently,  but  not  necessarily,  declares  the 
shoulder  at  the  orifice  of  the  uterus. 

1381.  Or  the  shoulder  itself  may  present  originally,  without 
the  hand  being  down,  as  a  necessary  consequence.  This  presen- 
tation is  more  frequent  than  any  other,  in  which  the  head,  knees, 
feet,  or  breech,  do  not  present.  The  roundness  of  the  shoulder 
favours  its  taking  this  position, 

1382.  I  have  chosen  to  consider  under  one  head  the  presenta- 
tions of  the  shoulder,  and  the  arm;  because,  the  indications  are 
precisely  the  same,  as  well  as  the  mode  of  acting,  for  the  arm 
itself  produces  no  essential  difference  in  treatment. 

1383.  Before  the  mouth  of  the  uterus  is  well  opened,  and  the 
membranes  are  rent,  it  is  difficult  to  distinguish  the  shoulder; 
but  when  these  changes  have  taken  place,  the  clavicle,  scapula, 
and  ribs  serve  to  distinguish  this  part. 

1384.  The  shoulder  may  present  in  four  different  ways  at  the 


PRESENTATION  OP  THE  ARM  AND  SHOULDER.       507 

superior  strait;  but  these  positions  become  very  difficult  to  dis- 
tinguish, unless  the  arm  be  down  at  the  same  time.*  When  the 
arm  is  down,  the  hand  will  serve  to  discover  the  position  of  the 
shoulder.  The  hand  will  offer  itself  at  one  of  the  sides  of  the 
pelvis;  and  its  back  or  palm,  will  present  either  anteriorly  or 
posteriorly:  the  position  of  the  shoulder  must  therefore,  in  such 
cases,  be  learnt  from  the  particular  situation  of  the  hand. 

13S5.  In  the  first  position  of  the  shoulder,  the  head  and  side 
of  the  neck  of  the  child  is  to  the  left  side  of  the  pelvis,  and  the 
7nght  arm  down;  the  back  of  the  hand  will  be  anterior,  the  palm 
pos-terior. 

1386.  In  the  second,  the  head  and  side  of  the  neck  will  be 
toward  the  left  iliac  junction;  the  palm  of  the  left  hand  w'lW  then 
face  outwards:  the  back  will  look  to  the  posterior  part  of  the 
pelvis. 

1387.  In  the  third,  the  head  and  side  of  the  neck  will  be  to  the 
right  side  of  the  pelvis ;  the  left  arm  down,  with  its  back  looking 
outwards,  and  the  palm  inwards. 

1388.  In  the  fourth,  the  right  arm  will  be  down,  with  its 
palm  looking  outwards,  and  its  back  inwards. 

1389.  If  turning  be  resorted  to,  it  will  avail  much  to  employ 
the  proper  hand.  In  the  first  and  fourth,  the  right  hand  must 
be  used;  in  the  second  and  third,  the  left. 

1390.  In  performing  this  operation,  the  rules  laid  down  for 
turning  in  general,  must  not  be  neglected;  that  is,  the  feet  must 
be  brought  down  in  such  a  manner  as  to  bend  the  spine  ante- 
riorly, &c.  &:c. 

1391.  The  presentations  now  treated  of,  are  certainly  very 
far  from  favourable;  yet  they  are  by  no  means  so  menacing  as  is 
commonly  represented.  If  these  labours  were  treated  according 
to  correct  principles,  they  would  offer  no  difficulty  beyond  what 
is  usually  encountered  in  turning,  unless  complicated  by  accident. 

•  Velpeau  tliinks  by  his  arrangement  of  these  presentations  of  the  shoulder, 
much  arfiblguity  is  avoided — he  designates  them  by  the  titles  of  "  dorso-pubic, 
dorso-sacral,  and  i-ight  and  left  dorso-iliac."  We  see  no  advantage  in  this — for 
in  proportion  as  distinctions  (which  are  necessarily  arbitraiy,)  are  multiphed, 
the  greater  will  be  the  confusion  to  the  student.  Indeed  Velpeau  admits  this 
liimself,  just  before,  and  instances  in  proof,  the  arrangements  of  Baudelocque, 
Meygrier,  and  Gardien — we  shall  therefore  continue  to  adopt  the  order  of 
Baudelocque,  especially  as  none  have  improved  upon  his  plan.  Velpeau,  we 
think  extremely  obscure  in  his  directions  for  the  management  of  "Shoulder 
presentations." 


508  PRESENTATION  OP  THE  ARM  AND  SHOULDER. 

(651)  But  if  the  favourable  moment  for  acting  be  not  taken 
advantage  of,  or  should  not  have  presented  itself,  much  difficulty 
may  be  experienced ;  and  the  case  becomes  subject  to  interference, 
by  cutting  instruments,  &c. 

1392.  It  should  be  constantly  borne  in  mind,  that  the  arm  it- 
self offers  no  indication,  save  that  of  pointing  out  the  position  of 
the  shoulder;  therefore,  no  manoeuvre  performed  upon  it,  can 
advance  the  interests  of  either  mother  or  child,  or  facilitate  the 
object  of  the  operator.  Consequently,  all  the  cruel,  as  well  as 
absurd  treatment  to  which  the  arm  is  sometimes  subjected,  such 
as  scarification,  amputation,  &.c.  should  always  be  avoided;  since 
it  can  never  improve  the  process  of  turning,  if  the  child  be  dead; 
and  it  will  almost  unnecessarily  destroy  it,  if  living. 

1393.  In  a  well-formed  pelvis,  the  presence  of  the  arm  offers 
no  embarrassment  to  the  operation  of  turning;  therefore,  every 
attempt  to  remove  it  from  the  inferior  portion  of  the  pelvis, 
either  by  trying  to  replace  it  within  the  uterus,  or  by  amputa- 
tion, is  only  losing  time,  or  improperly  irritating  the  parts,  or 
subjecting  the  protruded  part  to  an  unnecessary,  and  sometimes 
to  a  cruel  operation. 

1394.  There  is  no  presentation  that  gives  rise  to  so  much  bad 
practice,  as  the  presentation  of  the  arm;  for  its  mechanism  is  ge- 
nerally but  very  ill  understood.  The  arm  itself,  is  almost  con- 
stantly supposed  to  offer  great  difficulties,  by  its  presence  in  the 
vagina;  hence  it  has  been  scarified,  twisted  off,  or  amputated,  to 
the  disgrace  of  the  profession.  It  is  true,  that  in  most  instances 
these  severe  operations  have  been  performed  after  the  supposed 
death  of  the  child  ;  but  in  many  other  cases  we  fear,  that  the  life 
of  the  child  has  not  been  taken  into  consideration.-  (1396.) 

1395.  The  death  of  the  child  should  never  be  admitted  with 
too  much  facility ;  but  especially,  in  the  cases  under  considera- 
tion, as  no  operation  upon  the  arm  itself  can  ever  increase  the 
chance  of  gaining  the  feet.  Therefore,  in  arm  presentations,  the 
amputation,  or  other  operations  upon  it,  should  always  be  forbid- 
den; especially,  as  the  signs  of  death  ai*e  in  many  instances  as 
equivocal,  as  the  evidences  of  life  are  obscure. 

1396.  Chapman  relates  a  most  instructive  lesson  upon  this  sub- 
ject; a  lesson  which  should  always  be  present  to  the  mind  of 
him,  who  may  feel  disposed  to  act  in  defiance  of  the  best  experi- 
ence, by  amputating  the  arm,  under  the  pretext  that  the  child  is 
dead.     In  the  case  alluded  to,   the  accoucheur  amputated  the 


PRESENTATION  OP  THE  ARM  AND  SHOULDER.       509 

arm,  on  the  prcsuinption  that  it  was  dead;  it  was,  however,  alive, 
and  lived  to  manhood.  And  more  recently,  a  surgeon  was  sued 
for  amputating  the  protruded  arms  of  a  child  from  an  expiring 
mother,  and  where  it  was  not  possible  to  render  assistance  as  he 
believed  in  any  other  way.  The  child,  though  supposed  long 
dead,  proved  to  be  alive. 

1397.  It  is  therefore  best  not  to  meddle  with  the  descended 
arm;  for  if  turning  be  attempted,  it  offers  no  difficulty  to  the  pas- 
sago  of  the  hand  ;  and  if  the  crotchet,  or  any  cutting  instrument 
be  resorted  to,  it  cannot  interfere  with  its  operation. 

1398.  The  indication  in  these  presentations  is  to  bringdown  the 
feet,  and  deliver.  It  has,  however,  been  suggested,  that  we  may 
attempt  the  restoration  of  the  head  to  the  cavity  of  the  superior 
strait,  by  removing  the  shoulder  from  it;  I  believe  this  to  be  al- 
together theory.  I  do  not  even  advise  the  attempt;  for  indepen- 
dently of  its  difficulty,  I  am  persuaded  that  it  would  be  attended 
with  more  pain  and  risk  to  the  patient,  and  injury  to  the  child, 
than  a  well-conducted  turning. 

1399.  Mr.  Barlow  isof  ojjinion  that  this  is  practicable;  he  says, 
"  I  come  now  to  treat  of  that  species  of  preternatural  presenta- 
tion where  one  or  both  arms  present,  and  the  head  either  resting 
on  some  part  above  the  brim,  or  advanced  along  with  either  of  the 
superior  extremities  into  the  pelvis.  The  mode  of  delivery  sanc- 
tioned by  authors  in  this  division  of  presentation,  appears  involved 
in  some  degree  of  ambiguity;  for  little  variation  of  practice  has 
been  adopted,  whether  the  presentation  of  the  hand  or  hands  at 
the  brim  of  the  pelvis,  or  that  of  one  or  both  arms  descended  low 
in  the  vagina,  the  same  plan  of  delivery  in  every  state,  however 
dissimilar  the  case  may  be,  seems  to  be  invariably  pursued.  I 
conceive  there  requires  much  discrimination  as  well  as  variety 
of  practice  necessary  to  be  adopted,  according  to  different  situa- 
tions and  stages  in  which  the  foetus  is  found  to  present  under  this 
distinction  of  preternatural  presentation." 

1400.  "  If  the  accoucheur  has  the  management  of  a  case  of  this 
kind  from  the  time  of  the  discharge  of  the  liquor  amnii,  and  the 
hand  of  the  child  is  ascertained  to  present,  and  the  head  can  be 
brouglit  into  the  axis  of  the  pelvis,  it  should  be  effected  as  early 
as  the  state  of  the  os  uteri  will  admit,  and  the  i-eductiou  of  the 
hand  in  this  state  of  the  case  may  frequently  be  accomplished  by 
pushing  it  up  and  supporting  it  at  the  brim  of  the  pelvis  till  the 


510       PRESENTATION  OP  THE  ARM  AND  SHOULDER. 

head  becomes  engaged  in  the  superior  strait:  if  the  other  hand 
should  protrude,  it  may  be  encountered  by  a  similar  expedient. 
If  these  attempts  prove  ineffectual,  I  would  recommend  the  ac- 
coucheur to  introduce  a  piece  of  sponge  or  other  soft  substance 
along  the  cavity  of  the  pelvis  during  the  absence  of  pain,  and 
wedge  or  restrain  the  presenting  hand  or  hands  above  the  supe- 
rior strait,  till  the  head  has  cleared  the  brim  of  the  pelvis." 

1401,  On  these  directions  it  may  be  proper  to  remark,  that 
when  the  arm  or  arms  present,  it  can  never  be  proper  to  attempt 
to  bring  the  head  of  the  child  to  "  the  axis  of  the  pelvis,'"  and  for 
the  following  reasons;  first,  the  arms  cannot  present  before  the 
membranes  are  ruptured;  and  after  this  the  parts  will  have  de- 
parted to  some  distance  from  the  head:  and  in  proportion  as  they 
advance  in  the  pelvis,  will  the  head  depart  from  "the  axis  of  the 
pelvis."  Secondly,  it  most  frequently  happens,  that  at  the  mo- 
ment the  arm  has  escaped  from  the  orifice  of  the  uterus,  this  part 
is  no  more  dilated  than  is  sufficient  to  permit  the  arm  to  pass;  or 
if  it  has  been  more  largely  dilated  it  will  be  found  to  have  con- 
tracted itself  so  as  to  embrace  the  arm  pretty  strictly;  conse- 
quently, much  force  would  be  required  to  pass  the  hand  into  the 
uterus.  Thirdly,  that  if  the  hand  be  made  to  pass  the  contracting 
OS  uteri,  it  will  be  found,  that  its  operations  within  the  cavity  of 
this  organ,  will  be  extremely  limited,  and  by  no  means  adequate 
to  the  reduction  of  the  head.  For  every  attempt  to  change  its 
position  will  be  opposed  by  the  contracted  uterus,  which  now,  by 
virtue  of  its  tonic  power,  accoiDmodates  itself  to  the  various  ine- 
qualities of  the  surface  the  child  presents  to  it.  Fourthly,  if  it 
were  even  possible  to  restore  the  head  to  "  the  axis  of  the  supe- 
rior strait,"  the  arm  or  arms  would  accompany  the  head,  and 
thus  create  great  embarrassment  to  the  progress  of  tlie  labour, 
(718)  Fifthly,  I  believe  it  will  be  found  the  best  practice,  when 
we  are  under  the  necessity  of  introducing  the  hand  into  the  ute- 
rus in  such  cases,  to  finish  the  delivery  by  turning. 

1402,  Mr.  Barlow's  directions  respecting  the  attempt  to  return 
the  arm  or  arms,  I  believe  would  be  altogether  unavailing,  though 
as  we  have  said  elsewhere  (716)  that  the  hand  very  often  may  be 
prevented  from  prolapsing  into  the  vagina,  by  supporting  it  un- 
til the  head  shall  pass  under  it;  but  this  can  never  be  the  case 
with  the  arms.  It  will  be  seen  that  Mr,  B.  has  not  made  the  ne- 
cessary distinctions  between  the  hands  accompanying  the  head. 


PRESENTATION  OP  THE  All M  AND  SHOULDER.  511 

and  the  arm  presentation;*  for  the  latter  always  implies  the  exit 
of  the  arm  from  the  os  uteri;  while  in  the  former,  the  hands  are 
enclosed  in  the  uterus,  or  but  very  little  advanced  beyond  the 
edge  of  its  orifice.  Now,  there  is  an  essential  difference  between 
these  two  conditions,  and  they  require  very  different  modes  of 
treatment;  the  directions  of  Mr.  B.  may  answer  very  well  when 
only  the  hands  offer,  but  they  would  be  totally  inadequate  for  the 
restoration  of  the  head. 

1403.  When  the  arm  accompanies  the  head,  it  is  found  that 
it  almost  always  advances,  pari  passu ;  and  it  is  true,  that  this 
circumstance  is  not  always  subversive  of  the  natural  order  of  the 
labour.  But  this  can  only  happen,  vv^here  the  diameter  of  the 
head  and  arm,  do  not  exceed  the  diameter  of  the  pelvis.  See 
section,  on  the  presentation  of  the  hand  with  the  head,  p.  256, 
par.  716,  &c. 

1404.  The  circumstances  which  would  render  the  restoration 
of  the  head  to  the  axis  of  the  pelvis  practicable,  (if  it  be  practi- 
cable,) will  also  give  facility  to  bringing  down  the  feet;  namely, 
a  sufficient  relaxation  of  the  uterus,  and  the  absence  of  pain. 
Moreover,  if  these  conditions  obtain  in  the  first  instance,  it  will 
of  course  be  very  uncertain  whether  the  powers  of  the  uterus 
will  be  sufficiently  restored  to  expel  the  child  after  the  adjust- 
ment of  the  head;  consequently  much  time  might  be  lost,  and 
much  anxiety  be  created,  and  this  for  a  success,  that  is  altogether 
contingent. 

1405.  There  are  three  modes  of  proceeding  in  presentations  of 
the  arm;  the  first,  as  I  have  just  stated,  is  to  turn;  the  second,  to 
trust  to  the  powers  of  nature  to  produce  what  has  been  termed 
the ''spontaneous  evolution  of  the  child,"  and  the  third,  is  the 
employment  of  cutting  instruments  to  the  child  itself. 

1406.  When  the  arm  presents  in  a  labour  at  the  full  period  of 
utero-gestation,  we  should  entertain  no  hope  or  expectation  that 
nature  will  relieve  herself  while  the  child  continues  in  this 
position  ;t  consequently  this  case  must  be  always  regarded  as 
"  preternatural,"  and  the  bringing  the  child  by  the  feet,  is  the 

*  Mr.  Barlow  speaks  of  the  presentation  of  both  arms — a  presentation,  we 
have  never  seen,  though  we  do  not  pretend  on  this  account,  to  deny  such  an 
occurrence. 

t  Unless  the  rare  occui-rence  of  ««  spontaneous  evolution"  by  u  forced  con- 
struction be  considered  an  exception. 


513  OF  THE  CONDITION  OF  THE  UTERUS. 

only  operation  that  can  be  performed  with  a  view  to  tlic  safety  of 
both  mother  and  child. 

1407.  Notwithstanding  the  indication  in  this  case,  is  so  obvious, 
yet  it  is  not  always  practicable  to  fulfil  it.  This  arises  from 
— 1st.  the  condition  of  the  uterus;  and  2d,  from  the  situation  of 
the  arm  and  shoulder  within  the  pelvis. 

Sect.  I. — Of  the  Condition  of  the  Uterus. 

1408.  I  have  already  noticed  above,  (1392)  that  the  protruded 
arm  or  hand  offers  of  itself  no  difficulty  to  turning;  the  difficulty 
exclusively  depends  upon  the  condition  of  the  uterus,  and  espe- 
cially of  that  of  its  mouth.  If  both  be  in  such  a  state  of  relaxa- 
tion as  will  admit  the  passage  of  the  hand  without  much  force,  (as 
often  happens  soon  after  the  escape  of  the  waters,  where  the  la- 
bour has  progressed  regularly,)  no  more,  or  perhaps  sometimes 
even  less  difficulty  will  be  experienced,  than  in  turning  when  the 
head  presents,  and  the  uterus  equally  favourably  disposed. 

1409.  Our  attention  should  therefore  be  constantly  directed  to 
the  state  of  the  uterus,  and  especially  to  that  of  its  neck;  and  our 
conduct  should  be  regulated  alone  by  their  condition:  for  what- 
ever may  be  our  desire  to  aid  the  suffering  woman,  or  relieve  the 
threatened  child,  we  must  never  incur  the  risk  of  being  disap- 
pointed in  both,  by  forcibly  entering  the  resisting  OS  uteri.  When 
violence  has  been  committed  on  this  part  by  mechanically  mak- 
ing it  yield  to  the  hand,  inflammation,  laceration,  and  gangrene 
have  sometimes  followed;  nor  is  this  all:  the  operator  has  been 
foiled  in  his  attempt  to  bring  down  the  feet  by  the  os  uteri  con- 
tracting itself  round  his  wrist,  and  thus  obstructing  the  descent  of 
the  child.  I  once  witnessed  death  to  follow  immediately,  or  rather 
during,  a  rude  attempt  to  turn.  The  operator  had  with  great  diffi- 
culty passed  her  hand,  (the  patient  was  under  the  care  of  a  mid- 
wife,) through  the  os  uteri;  and  after  a  long  and  uncertain  search, 
became  possessed  of  the  feet:  in  attempting  to  bring  them  down, 
she  exerted  so  much  force,  as  to  rupture,  (I  believe,)*  the  uterus. 
The  poor  woman  expired  in  about  five  minutes  after  I  entered  the 

*  Tills  belief  is  founded  on  what  occurred  during  this  attempt  to  turn;  name- 
ly, a  slight  hemorrhage  from  the  vagina;  sickness,  and  vomiting;  cold  clam- 
my sweat,  &c. — of  the  pulse,  I  can  say  nothing;  it  was  extinct  when  I  saw  tlie 
patient — the  attendants  of  course  could  give  no  account  of  it,  and  the  midwife 
was  too  much  occupied  by  her  operation  to  examine  it. 


OP  THE  CONDITION  OF  THE  TTTEUUS.  513 

room,  and  while  the  midwife  was  still  exerting  all  her  force  upon 
tiie  legs  of  the  child.  The  persons  present  informed  me,  that  the 
midwife  after  she  had  learnt  I  had  been  sent  for,  declared  it  was 
unnecessary,  as  she  "  could  deliver  the  woman  as  well  as  any- 
body"— she  therefore  redoubled  her  exertions,  to  make  good  her 
assertion:  the  consequences  I  have  just  related.  She  most  indus- 
triously laboured  in  this  attempt,  for  more  than  an  hour, 

1410.  The  midwife  told  me,  that  "the  arm  had  been  down 
many  hours,  and  the  pains  were  very  strong" — but  added  "not- 
withstanding this,  the  child  did  not  come  nearer  the  world ;  I 
therefore  determined  to  wait  no  longer,  and  proceeded  to  turn,  as 
I  had  several  times  done  in  like  cases.  The  mouth  of  the  womb 
was  close  round  the  arm  of  the  child  ;  but  I  did  not  mind  this ; 
for  I  got  first  one  finger  in  it,  then  another,  and  at  last  mj^  whole 
hand.  But  indeed,  doctor,  this  was  hard  work.  When  I  got 
through,  I  never  was  so  long  finding  the  feet;  but  all  my  strength 
could  not  make  them  come  down;  and  the  poor  woman  died,  be- 
cause I  did  not  begin  sooner."  I  took  this  poor  ignorant  creature 
aside,  and  frankly  told  her,  she  had  destroyed  her  patient;  and 
exacted,  on  pain  of  exposing  her,  a  solemn  promise,  that  she 
would  never  attempt  the  like  operation  again. 

1411.  Therefore,  when  the  mouth  of  the  uterus  strongly  op- 
poses the  introduction  of  the  hand,  it  should  not  be  attempted;  in 
such  a  case,  it  will  almost  ahvays  be  found  if  the  waters  have 
been  long  drained  off,  that  the  tonic  contraction  of  the  body  and 
fundus,  will  also  offer  much  difficulty  to  turning.  This  being  the 
situation  of  the  patient,  nothing  can  justify  the  attempt  to  turn; 
for  one  of  the  following  consequences  will  almost  certainly  follow: 
1st.  If  the  hand  be  made  to  pass  the  stricture,  it  will  be  at  the 
expense  of  so  much  injury  to  the  neck  of  the  uterus,  that  the  one 
or  other  of  the  evils  stated  above  will  follow.  2d.  If  the  hand  be 
made  to  pass  the  constricting  os  uteri,  the  body  and  fundus  will 
offer  so  much  resistance,  as  to  defeat  the  safe  turning  of  the  child; 
or  3d.  If  the  child  be  safely  delivered,  it  may  be  at  the  expense  of 
the  life  of  the  mother. 

1412.  It  seems  then  to  follow,  that  this  condition  of  the  os 
uteri,  as  well  as  of  the  body  and  fundus  of  this  organ,  must  be 
changed  before  any  attempt  is  made  to  bring  down  the  feet  of 
the  child.  With  this  in  view,  we  must  induce  such  a  state  of 
relaxation,  as  shall  enable  the  hand  to  pass,  and  the  turning  to 
be  performed,  without  the  risks  stated.     This  can  be  almost  cer- 

05 


514  SITUATION  OF  THE  ARM  AND  SHOULDER 

tainly  effected,  by  a  sufficient  loss  of  blood.  To  exemplify  the 
practice  in  such  cases,  I  shall  relate  one,  from  my  "Essay  on  the 
Means  of  lessening  Pain,"  &c.  in  which  this  remedy  was  success- 
fully employed. 

1413.  "  1802,  January  29th,  Phoebe  Hall,  a  black  woman,  in 
labour  with  her  seventh  child;  arm  presented,  and  down  for  se- 
veral hours;  arm  considerably  swollen,  as  the  midwife  had  ex- 
erted considerable  force  upon  it;  the  mouth  of  the  uterus  con- 
tracting closely  round  it.  I  got  Dr.  Carter,  (a  gentleman  who 
accompanied  me,)  to  introduce  his  hand  into  the  vagina,  and 
place  a  finger  within  the  os  uteri — this  he  did  with  some  diffi- 
culty, as  the  uterus  was  very  rigidly  closed  upon  the  arm.  I 
tied  up  the  patient's  arm,  to  let  her  bleed  until  he  should  tell 
me  the  mouth  of  the  uterus  was  sufficiently  dilated.  When  1 
had  drawn  from  forty  to  fifty  ounces  of  blood,  she  became  sick 
and  faint;  at  this  instant  Dr.  Carter  cried  out  with  rapture  that 
the  uterus  was  sufficiently  dilated — upon  my  examining,  I  found 
it  to  be  the  case  ;  the  turning  and  delivery  were  soon  accom- 
plished." 

1414.  It  must  be  observed,  that  such  labours  as  are  attended 
with  fever,  always  require  the  loss  of  considerably  more  blood, 
than  when  none  attends;  and  it  has  been  found  best,  in  such 
cases,  to  draw  the  blood  at  two  or  three  operations;  but  carry- 
ing the  last  to  faintness,  or  at  least  to  sickness  of  stomach.  Now, 
the  labours  in  question  are  almost  always  accompanied  by  fever, 
if  they  have  been  long  protracted;  consequently,  will  frequently 
require  the  adoption  of  the  plan  just  proposed. 

Sect.  II. — Of  the  Situation  of  the  Jirm  and  Shoulder  within 
the  Pelvis. 

1415.  The  situation  of  the  arm  and  shoulder  within  the  pelvis, 
may  be  such  as  to  render  turning,  if  not  impracticable,  at  least 
unsafe. 

1416.  The  arm,  to  the  very  shoulder,  may  be  protruded 
through  the  os  externum;  and  the  shoulder  itself  so  impacted, 
and  the  contraction  of  the  uterus  so  firm,  as  to  render  it  impossi- 
ble to  turn,  with  any  prospect  of  success  to  the  child,  or  safety 
to  the  mother.  Our  conduct  in  this  situation  of  things,  must  be 
regulated  altogether  by  the  condition  of  the  child ;  and  this  will 
be  either  living,  or  dead.     It  must  therefore  be  ascertained  in 


WITHIN  THE  PELVIS.  515 

which  of  these  states  it  may  be,  before  we  decide  on  the  mode  of 
acting. 

1417.  With  a  view  to  determine  this,  the  hand  should  be  pass- 
ed into  the  uterus  until  it  reach  the  umbilical  cord — if  this  pul- 
sate, the  child  is  of  course  living ;  if  it  do  not  pulsate,  the  child  is 
cert  inly  dead. 

a.   The  Manner  oJ\Bcting,  if  the  Child  be  living. 

1418.  Having  ascertained  the  child  to  be  living,  our  conduct 
should  be  such,  as  to  give  it  the  best  possible  chance  to  be  deli- 
vered alive.  The  choice  of  means  will  lie  between  turning,  and 
waiting  for  the  spontaneous  evolution  of  the  child.  As  regards 
turning,  it  must  not  be  disguised,  that  it  is  an  operation  of  hazard 
to  the  child  even  under  the  most  favourable  circumstances  of  the 
uterus,  or  position  of  the  child;  and  of  course,  the  risk  will  be  in 
proportion  to  the  departure  from  these  best  conditions;  yet  it  of- 
fers in  this  case,  almost  the  only  alternative. 

1419.  In  the  situations  of  the  parts  in  the  presentation  now  un- 
der consideration,  two  diiBculties  will  necessarily  present  them- 
selves; 1st.  The  uterus  will  be  found  firmly  contracted  on  the 
body  of  the  child;  so  much  so,  sometimes,  as  to  render  it  almost 
impracticable  to  turn;  or  at  least,  it  would  be  hazardous,  unless 
the  operation  be  very  carefully  conducted.  In  such  a  case,  it 
should  not  be  attempted  but  with  the  utmost  caution,  and  not 
without  previously  endeavouring  to  diminish  the  resistance  of  the 
fundus  and  body  of  the  uterus  by  free  blood-letting,  as  just  pro- 
posed, for  the  rigidity  of  the  os  uteri,  when  it  creates  a  difficulty. 
After  the  patient  has  been  liberally  bled,  the  opposition  to  turn- 
ing is  sometimes  so  much  diminished,  as  to  render  the  opera- 
tion not  only  practicable,  but  safe  even  to  the  child.  Should  the 
blood-letting  procure  no  relaxation,  the  case  becomes  a  folorn 
one ;  especially,  for  the  child. 

1420.  We  should  not,  however,  for  this  reason,  abandon  the 
poor  woman  to  her  fate;  for  even  under  a  severe  contraction  of 
the  uterus,  a  well-directed  gentle  force  will  sometimes  overcome 
difficulties,  that  at  first  appeared  insurmountable  ;  especially,  after 
a  liberal  dose  of  opium.*  If  the  practitioner  be  inexperienced, 
he  should,  if  possible,  call  to  his  aid  a  more  skilled  operator.  He 
should  never  attempt  to  overcome  by  force,  the  difficulties  which 

*  It  will  be  borne  in  mind,  that  a  free  bleeding  must  be  performed,  before 
the  opium  is  given. 


516  SITUATION  OF  THE  ARM  AND  SHOULDER 

oppose  him;  a  proper  exercise  of  patient  address  sliould  ever 
govern  in  such  cases,  if  he  mean  to  succeed. 

1421.  Secondly.  In  consequence  of  the  firm  contraction  of  the 
uterus,  the  shoulder,  loe  are  told,  is  found  so  tightly  wedged  in  the 
inferior  strait,  as  sometimes  not  to  permit  the  slightest  motion 
upwards.  I  will  riot  sa)^,  that  this  is  never  the  case,  but  I  must 
declare,  it  seldom  happens,  unless  the  proper  time  for  acting  has 
been  lost,  either  reprehensibly  or  unavoidably.  So  far,  I  have 
never  met  with  a  case,  in  which  I  could  not  turn,  if  turning  were 
the  desirable  mode  of  acting:  but  this  has  arisen,  perhaps,  from 
having  been  generally  able  to  watch  the  proper  moment  for  the 
operation.* 

1422.  In  these  cases,  the  proper  moment  to  act,  is,  so  soon  as 
the  OS  uteri  is  sufficiently  relaxed  to  permit  the  passage  of  the 
hand;  and  if  this  relaxation  do  not  take  place  spontaneously,  it 
should  be  procured  as  early  as  the  nature  of  things  will  permit, 
by  blood-letting  and  opium;  and  this  as  soon  after  the  escape  of 
the  waters  as  practicable.  If  the  case  have  been  mismanaged, 
before  a  judicious  practitioner  has  been  consulted,  he  may  not 
perhaps  be  able  to  terminate  the  labour  by  turning,  with  any 
prospect  of  success  to  the  child;  he  is  then  to  consult  the  interest 
of  the  mother  alone;  and  this  will  perhaps  be  best  advanced  by 
waiting,  so  long  as  the  child  may  continue  to  live. 

1423.  But  should  any  accident  complicate  the  labour,  and  ren- 
der immediate  delivery  proper,  he  should  try  to  relieve  the 
patient  by  turning,  though  it  offer  but  a  bad  chance  for  the  pre- 
servation of  the  child.  If  this  be  impracticable,  (a  circumstance, 
I  am  warranted  in  saying,  of  rare  occurrence,)  he  must  relieve 
the  mother  at  the  expense  of  the  child,  as  will  be  directed  pre- 
sently. 

1424.  The  only  other  resource  which  presents  itself  for  the 
preservation  of  the  child,  is  waiting  for  what  is  termed  the 
^'spontaneous  evolution  of  the  child," 

h.  Of  Spontaneous  Evolution. 

1425.  Dr.  Denman,  I  believe,  was  the  first  to  notice  this  re- 

*  I  have  made  several  admissions  abo^  e,  tliat  woidd  appear  to  contradict, 
what  I  here  urge — the  cause  of  these  ackiiowledgTuents,  is  my  respect  for  the 
experience,  and  opinions  of  others,  though  not  borne  out  by  m)'  own  practice. 
I  say  also,  tliat  I  would  turn  when  tui-ning  was  the  desirable  mode  of  operating 
— mcanuig  by  this,  that  there  arc  exceptions  to  this  rule:  see  pai".  1427.;  also 
the  article  on  turning  in  deformity  of  the  pelvis. 


WITHIN  THE  PELVIS.  51 7 

rnarkahle  resource  of  nature,  in  shoulder  or  arm  presentations. 
He  enriched  the  profession  by  his  history  of  it,  and  by  instructing 
the  practitioner,  that  in  some  instances,  nature  achieves  with 
even  safety  to  the  child,  that  which  art  could  not  have  per- 
formed. His  explanation  of  this  phenomenon  is  highly  inge- 
nious, and  was  for  a  long  time  the  received  one;  but  it  appears 
to  have  yielded  to  that  of  Dr.  Douglass,  even  by  the  confession 
of  Dr.  Denman  himself.  See  Dr.  Douglass's  Essay  on  Sponta- 
neous Evolution.  There  is  a  case  lately  recorded,  where  the 
child  was  delivered  by  the  right  foot,  by  the  unaided  efforts  of 
the^uterus;  it  is  thus  related  in  the  "Bulletin  des  Scien.  Med." 
for  July,  1830,  page  95,  from  Siebold's  Journal  f  iir  Gebartzhiilfe, 
etc.  T.  viii.  3d  cap.  p.  712. 

Dr.  Schneider  was  called  to  a  woman  on  the  13th  of  Jul}^,  1822. 
He  was  informed,  that  the  child  had  presented  the  arm,  and  that 
the  delivery  was  efiected  by  the  powers  of  the  uterus  alone.  The 
people  present  could  not  inform  him  how  the  thing  happened;  but 
the  patient  declared,  that  the  waters  were  discharged  by  the  first 
pains,  and  that  an  arm  of  the  child  immediately  fell  into  the  va- 
gina. The  wom.an  instantly  sent  for  help,  but  in  a  i'ew  minutes 
after,  violent  and  almost  insupportable  pains  came  on,  during 
which  time  the  woman  felt  as  if  the  whole  abdomen  was  turned 
upside  down,  (bouleverse. )  Very  soon  after  the  right  foot  of  the 
child  escaped,  ar^d  then  the  trunk  and  head.  The  right  arm 
of  the  child  was  livid  and  swollen,  proving,  that  this  part  first 
presented  itself.  The  child  was  of  middling  size,  but  dead.  The 
pelvis  of  the  woman  was  very  large. 

1426.  This  chance  for  the  preservation  of  the  child,  is  however, 
of  extremely  rare  occurrence;  for  in  by  far  the  greater  number 
of  instances  of  "spontaneous  evolution,"  the  child  has  been  ex- 
pelled dead.  Indeed,  the  delivery  of  the  woman,  by  this  change 
of  position  of  the  child,  is  in  itself  very  rare.  I  have  never  seen 
a  case.  Yet  the  testimony  on  this  point  is  conclusive,  and  will 
justify  us  in  considering  it  a  resource,  after  all  the  rational  en- 
deavours have  failed. 

1427.  I  say,  a  chance  for  the  child;  for  such  only  should  it  be 
considered;  for  if  the  child  be  dead  we  have  no  longer  terms  to 
keep  with  it;  our  attention  must  be  solely  directed  to  the  safety 
of  the  mother.  1  should,  therefore,  recommend  waiting  for  this 
*' spontaneous  evolution,"  whenever  turning  forbad  the  hope  of 
saving  the  child;   provided  the   labour  be  not  complicated  by 


518  SITUATION  OP  THE  ARM,  &C. 

either  of  the  accidents  enumerated;  (651)  but  if  the  child  be  dead, 
and  this  ascertained  as  directed,*  (1417)  we  should  not  wait  for 
the  uncertain  event  of  "  spontaneous  evolution.'^ 

1428.  Dr.  Merriman  has  very  properly  observed,  "the  occur- 
rence of  the  spontaneous  evolution  has  been  comparatively  so  rare, 
that  no  man  would  be  justifiable  in  simply  relying  on  it.  The 
knowledge  that  it  has  sometimes  happened,  may,  indeed,  under 
some  circumstances  of  extreme  resistance  to  the  passage  of  the 
hand  into  the  uterus,  reconcile  us  to  the  delay  which  I  have  re- 
commended; but  we  should  never  allow  it  to  operate  upon  our 
minds,  so  as  to  induce  us  to  neglect  the  proper  means,  and  proper 
time  of  turning  when  we  have  it  in  our  power.  It  is  the  duty  of 
the  accoucheur,  on  all  occasions,  to  give  nature  every  possible  op- 
portunity of  exerting  herself  for  therelief  of  tlie  patient;  but  it  is 
equally  his  duty,  when  nature  becomes  embarrassed  and  oppres- 
sed, to  interpose  the  timely  assistance  of  art,  lest  nature,  being 
compelled  to  relinquish  the  task,  the  patient  shall  fall  a  sacrifice 
to  the  delay."t 

c.  Mode  of  Acting,  if  the  Child  be  Dead. 

1429.  If  it  be  ascertained,  that  the  child  is  dead;  and  it  should 
be  impracticable  to  turn,  we  must  attempt  the  delivery  of  the 
child,  by  the  use  of  instruments.  The  instruments  necessary  for 
this  purpose,  may  be,  the  scissors,  and  crotchet,  or  simply  the 
blunt  hook.  Before,  however,  either  is  employed,  the  uterus 
should  be  either  dilated,  or  dilatable;  and  this  will  almost  always 
be  found  to  be  the  case,  where  the  shoulder  is  forced  down  to  the 
OS  externum. 

1430.  In  this  situation,  we  can  always  command  the  thorax  or 
abdomen  of  the  child;  either  of  which  may  be  penetrated  by  the 
scissors;  and  these  aided  by  the  crotchet,  or  blunt  hook.  It  has 
been  recommended  by  several,  to  bring  down  the  head  by  pulling 
with  a  blunt  hook  fixed  over  the  neck.  It  would  seem,  that  this 
plan  was  first  suggested  by  Celsus;  it  is  however  claimed  for  one 
Home  by  Heister,  as  an  original  invention.  When  the  shoulder 
has  really  been  thrust  without  the  os  externum,  and  the  child 
certainly  ^eac?,  it  may-be  become  a  question,  which  of  the  two  pro- 
positions will  be  most  easy  to  fulfil.     Dr.  Sims  has  successfully 

*  It  miist  be  recollected,  we  can  pass  tlie  hand  to  the  umbilicus  of  the  child, 
when  it  might  be  impracticable  to  turn, 
f  Synopsis. 


WITHIN  THE   PELVaS.  519 

used  the  blunt  hook  upon  the  neck  of  the  child  in  at  least  two 
cases;  in  one,  the  head  was  delivered  without  separating  it  from 
the  neck;  the  other  was  attended  by  this  separation.  In  both  in- 
stances, the  child  had  been  dead  a  long  time.  I  can  say  nothing 
from  experience,  on  either  of  these  modes;  therefore,  will  not 
decide  positively  on  their  comparative  merits;  it  nevertheless 
strikes  me,  that  the  one,  which  will  be  attended  with  the  least 
risk  of  violence  to  the  soft  parts  of  the  mother,  should  be  prefer- 
red; and  that  appears  to  be  the  one,  which  will  diminish  the 
child's  bulk  before  it  is  forcibly  dragged  from  the  mother's  pelvis; 
therefore,  perhaps,  the  scissors  and  crotchet,  may  be  the  safer  me- 
thod in  this  respect. 

1431.  It  has  been  usual,  it  would  seem,  in  cases  where  turning 
was  impracticable,  to  wait  for  the  "  spontaneous  evolution"  to  take 
place;  but  I  would  not  recommend  this  plan,  when  it  is  certain 
the  child  is  dead;  and  for  these  reasons:  1st.  This  ''  evolution" 
is  not  certain  to  take  place;  2d.  If  it  do  not,  we  certainly  expose 
the  woman  to  much  suffering;  and  perhaps  even  to  danger,  for 
the  hope  of  this  favourable  contingency.  (1417)  The  British 
practitioners  being  much  more  familiar  with  these  untoward  cases 
of  arm  presentations,  do  not  hesitate  to  operate  with  cutting  instru- 
ments upon  the  child.  We  will  therefore  give  a  part  of  Dr.  Leed's 
mode  of  proceeding  in  such  cases. 

"On  the  15th  October,  1824,  I  was  called  to  visit  a  patient 
of  the  Westminster  General  Dispensary,  residing  in  Great  St. 
Andrew  Street.  I  found  her  in  the  following  condition.  The 
membranes  had  been  ruptured  fourteen  hours,  and  \kiQ  liquor  am- 
nii  had  entirely  escaped.  The  right  arm,  much  swollen  and  livid, 
was  protruding  out  of  the  external  parts,  and  the  shoulder  and 
part  of  the  thorax  were  firmly  impacted  in  the  pelvis,  while  the 
contractions  of  the  uterus  were  violent  and  incessant.  The  pulse 
was  quick,  the  face  flushed,  and  the  soft  parts  lining  the  pelvis 
were  hot,  dry  and  very  tender.  Thirty  ounces  of  blood  were 
drawn  from  the  arm,  and  sixty  drops  of  laudanum  administered, 
before  any  attempt  was  made  to  alter  the  position  of  the  child. 
After  waiting  for  half  an  hour,  when  the  pains  had  somewhat  di- 
minished in  violence,  I  attempted  slowly  to  pass  up  my  hand, 
but  the  pains  were  immediately  renewed  with  redoubled  force; 
and  after  persevering  for  upwards  of  an  hour  to  turn,  I  was  com- 
pelled to  abandon  the  intention.  Another  practitioner  then  saw 
her,  when  other  twenty  ounces  of  blood  were  drawn  from  the  arm, 


520  SITUATION  OP  THE  ARM,  &C, 

and  forty  drops  of  laudanum  were  administered.  He  waited  some 
time  in  tlie  hope  that  the  actions  of  the  uterus  would  cease  ;  but 
this  not  taking  place,  he  proceeded  to  endeavour  to  pass  up  his 
hand  into  the  womb.  This  attempt  again  excited  the  most  vio- 
lent bearing  down  pains ;  and  after  long  and  fruitless  exertions, 
he  was  also  compelled  to  desist  from  the  threatened  danger  of  rup- 
ture of  the  uterus. 

Two  hours  having  elapsed  after  this  second  attempt  to  turn, 
and  the  pains  still  continuing  undiminished,  I  separated  the  arm 
from  the  body  at  the  shoulder  joint,  laid  open  the  thorax  by  the 
means  of  the  crotchet,  and,  passing  it  through  the  opening  thus 
made,  fixed  it  on  the  lower  part  of  the  spine ;  and  on  dragging 
down  with  a  steady  force,  the  child  passed  out  of  the  external 
parts  doubled.  Though  there  was  great  distention  of  the  parts 
at  the  outlet  of  the  pelvis,  no  laceration  of  these  took  place. 

The  superior  aperture  of  the  pelvis  having  been  considerably 
under  the  ordinary  dimensions,  some  resistance  was  offered  to  the 
passa«'e  of  the  head  ;  but  this  was  overcome  without  much  diffi- 
culty. The  patient  speedily  recovered,  and  has  since  been  deli- 
vered by  me  of  an  eight  months'  child,  where  the  breech  present- 
ed, and  where  the  life  of  the  child  was  lost,  from  the  time  and 
force  required  to  bring  the  head  through  the  confined  brim  of  the 
pelvis. 

On  the  1st  May,  1S27,  I  was  requested  to  visit  JMrs.  Ka- 
gen,  Charles's  Street,  Drury  Lane,  also  a  patient  of  the  Westmin- 
ster General  Dispensary.  She  had  been  two  days  and  nights 
in  labour,  and  was  extremely  exhausted  with  fatigue.  The  left 
arm  much  swollen  was  presenting,  and  around  it  a  loop  of  the 
umbilical  cord,  which  did  not  pulsate.  There  was  great  thirst 
and  restlessness,  and  the  abdomen  was  tense  and  very  painful  on 
pressure.  The  pulse  was  extremely  quick.  The  uterus  was  con- 
tracting with  great  force,  and  I  found  it  quite  impracticable  to 
pass  up  the  hand,  or  to  push  back  the  presenting  part,  so  firmly 
was  it  impacted  on  the  pelvis.  Sixteen  ounces  of  blood  were 
drawn  from  the  arm,  and  an  opiate  administered  at  4  A.M.  At 
7  o'clock  the  pains  had  almost  ceased,  but  were  instantly  renewed 
on  attempting  to  turn.  The  child  being  dead,  I  did  not  perse- 
vere long  in  my  efforts  to  turn,  but  delivered  without  much  diffi- 
culty in  the  manner  already  described.  Here  also  there  was 
contraction  of  the  brim  of  the  pelvis,  of  which  a  lamentable  proof 
existed  in  a  fistulous  opening  between  the  bladder  and  the  vagina, 


WITHIN    THE    PELVIS.  521 

reported  to  have  been  caused  some  years  before  by  a  protracted 
labour,  which  was  ternunated  by  the  use  of  the  forceps. 

On  the  I4th  May,  1827,  I  was  called  to  a  patient  of  the  same 
Institution,  in  KingStreet,  Drury  Lane.  The  left  arm  presented, 
and  the  shoulder  and  thorax  were  forced  deeply  into  the  pelvis. 
The  umbilical  cord  was  hanging  without  the  external  parts  and 
did  not  pulsate.  The  contractions  of  the  uterus  were  strong,  and 
were  much  increased  on  attempting  to  introduce  the  hand.  The 
delivery  was  accomplished  with  the  utmost  ease,  and  in  a  very 
short  time,  as  already  described.  The  extraction  of  the  child  was 
effected  very  slowly,  to  allow  of  the  dilatation  of  internal 
parts,  and  to  prevent  laceration  of  the  perinceum.  On  the  se- 
cond day  after  delivery,  this  patient  experienced  a  slight  attack 
of  abdominal  inflammation,  which  readily  yielded  to  one  copious 
bleeding  and  cathartics. 

In  another  case  which  has  since  occurred  to  me,  and  which  in 
all  essential  circumstances,  resembled  the  three  now  detailed,  the 
same  method  of  accomplishing  delivery  was  adopted,  and  with 
similar  success. 

I  do  not  consider  it  necessary  to  define  more  clearly  the  cases 
to  which  the  above  practice  ought  to  be  applied,  as  it  is  hardly 
possible  for  any  one,  after  the  observations  I  have  made,  to  mis- 
understand the  object  of  this  communication,  or  to  suppose  that 
the  common  operation  of  turning  should  be  abandoned  where 
there  is  a  reasonable  hope  of  saving  the  child's  life,  and  that  of 
the  mother. 

The  method  of  effecting  delivery  above  mentioned,  I  was 
led  to  adopt,  from  reflecting  what  takes  place  in  cases  of  sponta- 
neous evolution  of  the  foetus;  and  it  may  be  perceived,  that  in  all 
the  foregoing  instances  nature  had  begun,  and  was  striving,  though 
ineffectually,  to  complete  this  process. 

Since  the  occurrence  of  these  cases,  I  have  had  an  opportunity 
of  perusing  the  essay  of  Dr.  Douglass  on  this  subject,  and  have 
been  gratified  to  find  he-  has  recommended  the  same  mode  of 
treatment,  and  has  been  also  forcibly  impressed  with  the  impro- 
priety of  turning  in  all  cases  of  arm  presentations.  Dr.  Sims,  in 
the  fortieth  volume  of  the  Medical  and  Physical  Journal,  stated 
similar  views  but  did  not  lay  down  any  specific  rule  of  practice 
in  such  embarrassing  cases. 

Dr.  Da^s  in  his  Elements  of  Operative  Midwifery,  p.   326, 
concludes  some  observations  on  this  subject  with  the  following 
66 


522  WITHIN  THE  PELVIS. 

words.  '  If  therefore,  we  suppose  the  child  to  be  ah-eady  dead, 
or  the  circumstances  of  the  labour  to  be  such  as  to  make  it  im- 
practicable to  bring  it  into  the  world  alive  by  means  of  turning, 
or  even  to  perform  that  important  operation  at  all  without  ex- 
posing the  mother  to  extreme  danger,  it  would  then,  in  my  opi- 
nion, be  the  unquestionable  duty  of  the  practitioner  to  eifect  the 
delivery  by  embryotomy.' 

Instead  of  extracting  the  child  double,  he  recommends  '  that 
it  should  be  divided  into  two  principal  parts,  head  and  body, 
by  passing  a  properly  adapted  cutting  instrument  across,  and 
through  the  entire  structure  of  the  neck;'  and  he  has  delineated 
in  his  invaluable  work  instruments  for  this  purpose. 

Notwithstanding,  however,  his  ingenious  invention  of  cranio- 
tomy forceps,  and  of  the  power  which  they  confer  upon  us  of 
extracting  the  head,  or  any  other  part  of  the  child  from  the  ute- 
rus, still  I  should  be  disposed  to  avoid,  if  possible,  the  occurrence 
of  the  head  remaining  in  the  cavity  of  the  uterus  after  the  extrac- 
tion of  the  body,  as  it  must  be  extremely  difficult  to  find  after- 
wards for  perforation,  and  quite  impossible  to  accommodate  it  to 
the  diameters  of  the  pelvis  in  passing. 

The  difficulty  of  reaching  the  neck  when  the  shoulder  and 
thorax  are  thrust  deep  into  the  pelvis,  and  the  head  of  the  child 
is  tilted  up  over  its  brim,  appeared  to  me  in  the  preceding  cases 
so  great  as  to  be  almost  insuperable,  setting  aside  the  disagreeable 
process  of  passing  uji  cutting  instruments  so  high  within  the  ute- 
rus. " 


)23 


CHAPTER  XXXVIIT. 

ON    PRESENTATIONS,   WITH  THE  FALLING  DOWN  OP    THE  UMBILI- 
CAL   CORD. 

1432.  We  have  already  expressed  our  surprise,  that  the  cord 
does  not  more  frequently  accompany  the  presenting  part,  and  by 
its  presence  embarrass  the  labour,  than  it  is  found  to  do.  Yet  a 
prolapsus  of  the  cord  is  comparitively,  and  fortunately,  a  case  of 
rare  occurence. 

1433.  It  will  readily  occur,  that  a  labour  complicated  with 
the  descent  of  the  cord,  can  only  be  threatening  to  the  child; 
since  the  cord  being  down,  cannot  of  itself,  interfere  with  the  me- 
chanism of  a  labour,  or  influence  its  duration ;  consequently,  can 
offer  no  threat  to  the  mother.  It  is  then  the  safety  of  the  child 
alone,  that  claims  our  attention,  or  that  presents  us  with  any 
specific  indication  ;  for  on  its  welfare  we  must  base  all  our  rules 
of  conduct.  For,  if  the  child  be  dead,  and  this  can  be  determined 
by  the  want  of  pulsation  in  the  cord,  the  funis  being  down,  should 
not  alone  make  us  interfere  with  the  labour.  For  Dr.  Denman 
has  very  justly  observed,  ''  it  is  only  when  the  child  is  living, 
that  any  interposition  can  be  required,  or  be  of  service  ;  yet  it  is 
remarkable,  that  writers  on  this  subject  have  instituted  their  di- 
rections in  general  terms  with  regard  to  the  state  of  the  child, 
whether  living  or  dead." 

1434.  We  may  sometimes  determine,  that  the  cord  will  pro- 
lapse, even  before  the  membranes  have  given  way  ;  for  it  may 
sometimes  be  felt,  either  single,  or  in  folds,  immediately  before 
the  presenting  part.  Its  peculiar  form,  and  its  pulsations,  can  be 
perceived  behind  the  membranes  in  the  absence  of  pain,  if  the 
finger  be  placed  against  them,  and  the  os  uteri  be  sufficiently 
open  ;  and  this  at  once  decides  the  nature  of  the  case.  When 
this  happens,  it  may  be  looked  upon  as  an  important  warning,  as 
it  directs  us  to  a  peculiar  observance  in  practice  ;  but  if  it  only 
declare  itself  after  the  rupture  of  the  membranes,  by  falling  into 
the  vagina,  we  necessarily  loose  the  advantage,  that  a  previous 
knowledge  that  this  was  about  to  take  place,  would  give  us. 

1435.  Some  have  attributed  this  accident  to  t!ic  uterus  being 


524  OF  PRESENTATIONS,  WITH  THE 

unusually  loaded  with  the  liquor  amnii;  but  we  believe  witiiout 
sufficient  reason  ;  for  we  have  seen  most  abundant  flows  of  this 
fluid  unattended  by  this  accident;  and  we  have  certainly  wit- 
nessed it,  where  the  quantity  was  not  uncommonl}'  great.  Others 
have  ascribed  it  to  an  unusual  length  of  cord  ;  this  is  more  pro- 
bable; since,  it  is  presumable,  that  this  circumstance  would  in- 
crease the  liability  to  the  accident,  though  perhaps  it  may  not  be 
essential  to  it :  we  may  at  all  events  most  safely  affirm,  that  we 
have  seen  cords  of  great  length,  where  this  protrusion  did  not 
take  place. 

143G.  Perhaps  it  may  be  truly  said,  that  this  event  is  alto- 
gether accidental,  or  contingent;  though  Dr.  Denman  declares 
that  some  women  appear  more  liable  to  it  tlian  others :  it  would 
certainly  be  difficult,  were  this  even  the  fact,  to  determine  in  what 
the  predisposition  consists,  as  it  does  not  seem  to  dejf&nd  upon 
cither  the  quantity  of  liquor  amnii  or  the  length  of  the  cord. 

1437.  I  have  said,  that  the  circumstance  of  the  cord,  preceding 
the  presenting  part  of  the  child,  is  altogether  perhaps  accidental, 
or  contingent ;  I  believe  this  to  be  the  case,  from  the  difficulty 
of  assigning  the  predisposing  causes,  as  just  observed,  and  the 
extreme  rarity  of  the  occurrence.  I  am  of  opinion,  that  when 
this  happens,  the  following  circumstances  must  take  place;  first, 
that  the  cord  must  be  precipitated  before  the  presenting  part, 
and  made  to  rest  against  the  membranes  ;  in  this  case,  the  pro- 
lapsing of  the  cord  would  be  inevitable;  and  the  cause  of  this  si- 
tuation of  the  cord,  must  be  hidden  perhaps  in  the  same  obscurity, 
as  any  other  deviation  in  the  presentation  of  the  child  itself.  Se- 
cond, that  if  the  cord  should  not  originally  offer  with  the  present- 
ing part,  then  two  circumstances  must  obtain,  that  the  floating 
cord  may  be  carried  without  the  os  uteri ;  and  these  appear  to 
be,  first,  a  small,  but  powerful  current  instead  of  the  diff'used  and 
feeble  discharge  of  the  liquor  amnii ;  and  second,  that  this  current 
must  meet  in  its  course,  a  portion  of  the  cord  sufficiently  long  and 
disengaged,  to  be  carried  by  it  without  the  uterus.  If  it  be  ask- 
ed, how  can  this  partial  current  be  established,  and  endowed,  with 
an  adequate  power  to  produce  the  accident  in  question  ?  I 
would  answer,  by  the  head  or  presenting  part  of  the  child  occu- 
pying the  superior  strait  so  strictly,  as  to  prevent  the  escape  of 
the  waters,  but  from  a  small  portion  of  that  opening ;  and  the 
force  with  which  the  liquor  amnii  shall  escape,  will  necessarily  be 
conimcjisuratc  with  the  power,  with  which  it  is  urged ;  or  in  other 


i 

i 


FALLING  DOWN  OF  THE  UMBILICAL  CORD.  525 

words,  it  will  be  driven  with  an  impetus,  equal  to  the  force,  with 
which  the  uterus  contracts. 

1438.  We  need  but  insist  in  confirmation  of  this  conjecture, 
that  the  presenting  part  every  now  and  then  does  so  completely 
occupy  the  superior  strait,  as  to  dam  the  waters  above  it,  and 
thus  create  difficulty  and  delay  in  the  labour;  hence,  the  direc- 
tion to  raise  the  head,  that  the  waters  may  escape. 

1439.  But  a  truce  with  conjecture;  it  is  enough  for  all  practi- 
cal purposes,  (since,  did  we  know  the  cause,  we  could  not  pre- 
vent the  effect,)  that  the  cord  does  precede  the  presenting  part; 
and  that  under  two  circumstances,  as  w^e  have  just  stated.  It  is 
proper  to  observe,  however,  that  each  condition  in  v/hich  the  cord 
may  prolapse,  requires  some  difference  of  management. 

1440.  ^V"e  will  first  notice  the  cases  in  which  the  presence  of  the 
cord  is  detected,  before  the  waters  have  escaped. 

1441.  It  almost  supposes  the  os  uteri  to  be  opened  to  some  ex- 
tent, when  we  are  able  to  detect  the  presentation  of  the  cord, 
since  it  requires  some  space  to  ascertain  satisfactorily  its  presence; 
at  least  with  sufficient  certainty  to  make  us  determine  on  one 
mode  of  proceeding,  in  preference  to  another. 

1442.  We  are  directed  in  such  cases,  both  by  Dr.  Denman  and 
]Mr.  Burns,  if  the  cord  prolapse,  and  the  os  uteri  be  but  little  open- 
ed rather  to  wait  the  issue  of  the  natural  progress  of  the  labour, 
than  to  forcibly  enter  the  uterus;  in  this,  we  perfecly  agree. 
But  Mr. Burns,  immediately  after  advises,  "  as  soon  as  the  os  uteri 
will  admit  the  introcUiclion  of  the  hand,  the  child  should  be  turned, 
if  it  can  be  easily  done."  And  Dr.  Denman  seems  inclined  to  the 
same  mode  of  treatment,  (hough  a  little  more  precise,  and  more 
guarded  upon  this  subject  than  Mr.  Burns;  but  both  are  advo- 
cates, under  certain  restrictions,  for  turning. 

1443.  Mr.  Burns  declares  the  sum  of  practice  in  this  case  to  be, 
1st,  "that  when  the  os  uteri  is  not  dilated,  so  as  to  permit  turn- 
ing, we  must  not  attempt  it;  but  when  turning  is  practicable,  it  is 
to  be  performed;  2d,  when  the  head  has  descended  into  the  pel- 
vis, the  cord  is  to  be  replaced;  3d,  or  secured  as  much  as  possible 
from  pressure;  4th,  but  if  the  circulation  be  impeded,  the  woman 
must  be  encouraged  to  accelerate  the  labour  by  bearing  down, 
or  instruments  must  be  employed;  5th,  when  the  presentation  is 
preternatural,  these  directions  are  to  be  attended  to,  and  the 
practice  is  also  to  be  regulated  by  the  general  rules  applicable  to 
such  labours." 


526  ON  PRESENTATIONS  WITH  THE 

1444.  Wc  shall  examine  each  of  these  directions  in  order,  and, 
1st,  "  that  when  the  os  uteri  is  not  dilated,  so  as  to  permit  of  turn- 
ing, we  must  not  attempt  it;  when  turning  is  practicable,  it  is  to 
be  performed."  Dr.  Denman  more  cautiously  advises, "  if  the 
child  be  living,  and  the  presenting  part  high  up  in  the  pelvis,  es- 
pecially, if  the  pains  have  been  slow  and  feeble,  it  will  generally 
be  better  to  pass  the  hand  into  the  uterus,  to  turn  and  deliver  the 
child  by  the  feet;  using  at  the  same  time  the  precaution  of  car- 
rying up  the  descended  funis,  that  it  may  be  out  of  the  way  of 
compression."  But,  notwithstanding  these  positive  directions,  I 
am  inclined  to  think  that  the  question  to  be  solved  in  such  cases 
is,  1st,  whether  it  be  ever  proper,  to  turn  for  the  mere  presence 
of  the  cord;  and,  2d,  if  it  be,  what  are  the  circumstances  which 
render  it  so? 

1445.  Turning  must  always  be  looked  upon  as  of  doubtful  safety 
to  the  child;  (736)  its  adoption  must  therefore  be  constantly 
regarded  as  a  choice  of  evils.  In  a  case  of  prolapsed  funis, 
it  should  be  resorted  to  with  great  caution,  especially,  as  there 
is  no  question,  that  children  are  frequently  born  alive  after 
the  cord  has  been  prolapsed,  and  when  the  progress  and  termina- 
tion of  the  labour  was  confided  to  the  natural  powers.  While  on 
the  contrary,  the  fact  is  equally  well  established,  that  they  have 
perished  during  the  extraction;  and  I  believe  we  may  safely  say 
with  Baudelocque,  "  and  all  this,  in  cases,  where  they  might 
have  been  born  alive,  notwithstanding  the  exit  of  the  cord,  had 
the  delivery  beenjeft  to  nature." 

1446.  "  For,"  adds  he,  "  after  the  discharge  of  the  waters  which 
brought  it  (the  cord)  out,  the  expulsion  of  the  child  is  often 
quicker  than  its  extraction  could  be;"  therefore,  "  we  should  in 
all  such  cases,  add  a  long  compression  of  the  cord,  to  the  danger 
sometimes  inseparable  from  turning  the  child,  and  bringing  it  by 
the  feet." 

1447.  Now,  as  it  is  admitted,  that  children  have  been  born 
alive,  when  nature  has  not  been  interfered  with,  though  the  funis 
had  presented,  it  follows,  that  this  part,  in  such  cases,  does  not 
necessarily  suffer  compression;  consequently,  turning,  as  a  gene- 
ral practice,  should  not  be  inculcated,  especially  as  we  can  often 
avert  this  dreaded  pressure,  by  carrying  the  cord  to  that  side  of 
the  pelvis  to  wliich  it  may  most  incline;  or  by  restoring  the  funis 
within  the  uterus,  beyond  the  risk  of  this  accident. 

144S.   Turning  can  only  be  considered  as  the  better  means, 


FALLING  DOWN  OF  THE  UMBILICAL  CORD.  527 

when  no  farther  reliance  can  be  placed  on  the  powers  of  nature 
to  eflcct  the  delivery  in  proper  time;  or  when  the  cord  suffers 
either  constant  or  occasional  compression;  either  of  which  if  con- 
tinued beyond  a  certain  time,  will  inevitably  de'stroy  the  child.  It 
is  not  suflicient,  because  the  pains  are  feeble  and  long  in  return- 
ing, to  make  us  conclude,  that  the  powers  of  nature  arc  incompe- 
tent to  the  end,  and  make  us  resort  to  tlie  doubtful  expedient  of 
turning;  for  unless  the  cord  be  threatened  with  compression  at  the 
same  time,  the  mere  tardiness  of  labour,  especially  at  the  earlier 
part  of  it,  oflisrs  no  immediate  indication. 

1449.  For  we  may  in  many  cases,  urge  the  reluctant  powers 
of  the  uterus  to  proper  and  efficient  action,  or  restore  them  when 
they  have  flagged  from  exhaustion.  The  first,  is  sometimes  suc- 
cessfully accomplished  by  bleeding,  a  stimulating  injection,  or 
by  opium ;  the  latter,  oftentimes  most  happily,  by  the  secale 
cornutum. 

1450.  It  may  however,  be  necessary  to  turn,  or  otherwise 
treat  this  case,  if  it  be  complicated  by  other  accident;  but  the 
propriety  and  nature  of  the  choice,  must  be  governed  by  the  na- 
ture and  force  of  the  additional  complaint.  Or  it  may  become 
absolutely  necessary  to  turn,  if  the  presentation  be  preternatural, 
agreeably  to  our  acceptation  of  the  term;  (615)  and  often,  highly 
expedient,  at  least  to  interfere  with  the  regular  course  of  the 
labour,  when  either  the  breech,  feet,  or  knees,  shall  offer.  Thus, 
if  the  breech,  feet,  or  knees  present,  it  may  become  necessary, 
for  the  preservation  of  the  child,  to  bring  down  the  feet^  and 
finish  the  labour  by  artificial  aid. 

1451.  It  should,  however,  constantly  be  borne  in  mind  that 
even  when  we  determine  on  this  operation,  it  should  be  subject 
to  all  the  regulations  we  have  already  imposed  upon  it.  See 
Chapter  "On  Turning." 

1452.  When  we  have  ascertained,  that  the  funis  is  below  the 
presenting  part,  I  would  depart  from  the  rule  I  have  laid  dovvn, 
(544)  of  rupturing  the  membranes;  I  would,  in  this  case,  pre- 
serve them  with  the  most  scrupulous  care,  by  not ''  touching;"  by 
strict  rest  on  the  part  of  the  patient;  and  cautioning  her  against 
bearing  down.  By  these  means  we  may  prevent  the  yielding  of 
the  membranes  until  the  last  period  of  labour ;  and  of  course, 
prevent  the  compression  of  the  cord,  I  do  not  know  that  this 
plan  has  hitherto  been  recommended ;  though  so  obviously  im- 
portant, when  it  can  be  complied  with.     I  can,  however,  only 


528  ON  PRESENTATIONS,   WITH  THE 

speak  of  its  utility,  in  a  single  case.  I  ascertained  in  the  early- 
part  of  a  certain  labour,  that  the  cord  was  presenting;  and  made 
up  my  mind  not  even  to  touch  my  patient  until  the  pains  should 
declare  the  last  period  to  be  at  hand.  Upon  examination  at  the 
time  I  thought  proper,  I  found  the  membranes  ready  to  protrude 
the  OS  externum ;  and  in  which,  I  could  distinctly  feel  the  pro- 
lapsed and  pulsating  funis.  The  head  of  the  child  was  about  to 
emerge  from  under  the  pubes;  and  the  soft  parts  pliant,  and 
every  way  disposed  to  yield.  I  now  ruptured  the  membranes, 
and  the  head  and  body  almost  immediately  followed  the  discharge 
of  the  waters.     The  child  was  healthy,  and  cried  lustily. 

1453.  I  do  not  wish  more  consequence  to  attach  to  this  plan 
than  it  deserves;  for  I  must  confess,  it  is  no  direct  evidence,  that 
the  safety  of  the  child  depended  upon  maintaining  the  integrity 
of  the  membranes  to  so  late  a  period;  as  we  know  that  the  same 
happy  results  have  followed  delivery  in  cases  of  the  falling  of  the 
cord  without  this  precaution  having  been  observed.  Yet,  one 
thing  is  nearly  certain;  that  the  funis  cannot  be  either  very  long, 
or  very  severely  compressed,  so  long  as  it  is  retained  within  the 
entire  membranes.  This  plan  would  be  particularly  important 
with  a  first  child;  or  where  the  uterus  opens  reluctantly;  or 
where  the  labour  progressed  slowly,  and  the  external  parts  offer 
much  resistance.  It  must,  however,  be  granted,  that  it  cannot 
always  be  carried  into  execution,  as  there  are  several  causes 
which  may  rupture  the  membranes,  besides  design  ;  yet,  never- 
theless, when  it  can  be  done,  we  think  it  should  be  done. 

1454.  2d.  "When  the  head  has  descended  into  the  pelvis," 
says  Mr.  Burns,  "  the  cord  is  to  be  replaced,  or  secured  as  much 
as  possible  against  pressure ;  but  if  the  circulat'.on  be  impeded, 
the  woman  must  be  encouraged  to  accelerate  the  labour  by  bear- 
ing down,  or  instruments  must  be  employed." 

1455.  This  rule  necessarily  divides  itself  into  several  very  im- 
portant, ill-defined  directions;  it  will,  therefore  be  necessary  to  its 
investigation,- that  we  consider  them  separately. 

1456.  First.  "When  the  head  has  descended  into  the  pelvis, 
the  cord  is  to  be  replaced."  This  direction  has  always  been  a 
oreat  desideratum  in  the  treatment  of  labours  complicated  by  the 
presence  of  the  cord,  and  various  plans  have  been  suggested  by 
several  ingenious  and  experienced  members  of  the  profession,  nei- 
iher  of  which,  however,  has  been  very  successful.     The  crutch 


FALLING  DOWN  OF  THE  UMBILICAL  CORD.  529 

of  Burton;  the  leather  purse  of  Mackensie;  the  attempt  at  its 
suspension  of  Croft,  have  been  alike  unrewarded  by  success. 

1457.  A  more  plausible  method  has  lately  been  suggested  by 
Dr.  Dudan,  which,  he  says,  has  been  crowned  with  success  in  the 
instance  in  which  it  was  tried.  He  proposes  "to  carry  the  pro- 
lapsed portion  of  the  funis  into  the  uterus  by  means  of  a  gum 
elastic  male  catheter  and  ligature,  in  the  manner  following: — The 
catheter  should  be  of  the  size  of  No.  8  or  9,  with  its  stillet;  a 
piece  of  narrow  riband,  or  several  thicknesses  of  strong  thread  of 
sufficient  length,  well  waxed,  must  be  introduced  into  the  last 
eye  of  the  catheter,  and  retained  there  by  the  extremity  of  the 
stillet.  The  cord  must  now  be  attached  by  the  riband  encircling 
it,  w  ithout  drawing  it  too  tight.  If  the  loop  of  the  cord  be  short, 
or  not  more  than  seven  or  eight  inches,  it  may  be  tied  in  the  mid- 
dle; but  if  longer,  it  should  be  doubled,  and  tied  towards  the  cen- 
tre of  the  fold." 

1458.  "  The  cord  must  be  returned  within  the  uterus  at  one  of 
the  sides  of  the  pelvis;  if  it  be  carried  to  the  right  side,  the  right 
hand  should  be  used;  if  to  the  left,  the  left  hand,  making  the  op- 
posite hand  serve  as  the  guide  to  pass  it  between  the  head  of  the 
child  and  the  neck  of  the  uterus.  As  soon  as  the  loop  is  found 
to  penetrate  between  the  head  and  uterus,  it  should  be  pushed 
with  considerable  force,  and  without  our  having  fears,  we  may 
stop  the  circulation  within  the  cord;  or  should  it  be  interrupted 
for  a  short  time,  it  is  of  no  consequence.  At  the  same  time  with 
the  hand  which  serves  as  a  guide,  we  may  assist  the  passage  of 
the  cord  within  the  uterus,  and  at  the  same  time  prevent  its  slip- 
ping in  the  loop  of  the  riband." 

1459.  "  When  the  cord  is  returned,  we  need  be  in  no  haste  to 
withdraw  the  catheter;  on  the  contrary,  we  should  v/ait  until  the 
pains  have  made  the  head  of  the  child  engage  in  the  superior 
strait,  when  it  acts,  if  it  may  be  so  expressed,  as  a  cork.  Then 
the  stillet  must  be  withdrawn,  and  the  catheter  can  easily  be  made 
to  follow.  The  riband  may  remain,  as  it  will  be  expelled  with 
the  child." 

1460.  This  project  I  believe  to  be  better  than  any  other 
hitherto  proposed,  as  it  gives  more  entire  command  of  the  pro- 
lapsed cord,  and  by  a  means  which  cannot  injure  either  mother 
or  child.  This  plan  so  nearly  resembles  one  I  proposed  some 
years  ago,  th-t  they  might  well  pass  for  the  same.  But  that  of 
Dr.  Dudan  is  in  one  respect  a  considerable  improvement  on  that 

67 


530  ON  PRESENTATIONS,  WITH  THE 

of  mine,  by  substituting  the  flexible  male  catheter  for  a  piece  of 
plain  steel  of  proper  size,  with  an  eye  to  it,  as  I  had  proposed; 
while  that  of  mine  has  perhaps  an  advantage  in  the  mode  of  ap- 
plying the  riband,  or  ligature. 

1461.  In  Dr.  Dudan's  plan  which  by  the  by  he  describes  very 
ill,  the  riband  is  tied  over  the  cord  with  sufficient  tightness,  and 
the  ends  are  passed  through  the  eye  of  the  catheter,  and  fastened 
within  the  canal  by  pushing  up  the  stillet;  while  in  my  method 
the  riband  is  passed  round  the  cord  without  tying;  the  ends  are 
then  passed  through  the  eyes  by  withdrawing  the  stillet  suffi- 
cienily  to  leave  them  clear;  the  extremities  of  the  riband  are  then 
drawn  sufficiently  tight  to  place  the  cord  and  catheter  in  contact. 
The  advantage  of  this  method  is,  that  we  can  always  regulate  the 
degree  of  compression  upon  the  cord;  or  we  may  take  it  off  al- 
together if  desirable;  whereas  in  the  other  it  must  always  remain 
the  same. 

1462.  As  these  plans  are  rather  difficult  to  comprehend  from 
description,  1  have  added  drawings  by  way  of  illustration.  It 
will  be  seen  that  I  have  availed  myself  of  Dr.  Dudan's  suggestion 
of  the  flexible  catheter.  See  plate  XVII,  and  explanation.  But 
to  proceed. 

1463.  3d.  "Or  secnrcd  as  much  as  possible  from  compres- 
sion;" to  do  this,  we  are  directed  by  almost  all  the  writers  upon 
this  subject,  to  carry  the  cord  to  one  of  the  sides  of  the  pelvis, 
and  the  side  nearest  to  the  prolapsed  portion  is  always  the  best. 
We  can  sometimes  succeed  for  a  time  in  preventing  the  com- 
pression of  the  cord  by  this  plan,  but  it  will  be  readily  understood 
that  this  cannot  be  permanent;  as  the  head  in  changing  its  posi- 
tion to  place  itself  under  the  arch  of  the  pubes,  will  press  upon  it 
with  more  or  less  force  and  certainty.  The  child  will  now  be  in 
great  jeopardy,  and  if  not  very  speedily  delivered  will  die. 
The  woman  should  be  solicited  to  aid  herself  as  much  as  possi- 
ble, or  the  ergot  should  be  given  with  a  view  to  hasten  the 
labour. 

1464.  4th.  "I3ut  if  the  circulation  be  impeded,  the  woman 
must  be  encouraged  to  accelerate  the  labour,  by  bearing  down,  or 
instruments  must  be  employed." 

1465.  This  direction  is  more  vague,  perhaps,  than  any  of  the 
preceding;  it  runs  counter  in  its  tendency,  if  literally  interpret- 
ed, to  the  advice  of  the  most  respectable  authorities  upon  this 
subject;  for  if  the  circulation  be  arrested,  the  child  will  certainly 


TALLINCr  DOWN  OP  THE  UMBILICAL  CORD.  531 

die  in  the  course  of  a  very  few  minutes;  and  if  the  circula- 
tion have  been  stopped  sufficiently  long  to  cause  the  death  of 
the  child,  it  is  agreed  upon  all  hands,  and  even  by  Mr.  B.  him- 
self, the  labour  should  not  be  meddled  with,  as  it  would  be  un- 
availing to  do  so  ;  consequently,  the  woman  need  not  be  urged  to 
unusual  exertion,  nor  should  instruments,  or  any  other  artificial 
means  be  thought  of. 

1466.  It  is  by  no  means  uncommon,  for  the  life  of  the  child 
to  be  threatened  in  a  case  of  the  prolapsus  of  the  cord,  when  the 
head  is  low  in  the  pelvis;  as  there  is  a  constant  liability  to  its  being 
placed  between  the  head  and  the  pelvis,  and  thus  suffer  more 
or  less  compression;  we  have  already  provided  for  this  condition, 
(1449)  when  delivery  can  be  performed  in  time  to  save  the  child, 
by  the  exertion  of  the  woman,  or  by  increasing  the  power  of  the 
uterus  by  the  exhibition  of  the  "  Ergot;"  or  if  the  forceps  can  be 
commanded  in  time,  they  may  sometimes  be  advantageously  em- 
ployed. 

1467.  Now  Mr.  Burns  vaguely  prescribes  the  use  of  ^Hnstru- 
mentsf  the  choice  of  a  proper  one,  might  embarrass  a  youno- 
practitioner;  though  we  are  disposed  to  admit,  that  Mr.  B.  would 
select  for  his  own  use,  either  the  forceps  or  the  vectis,  for  he  had 
just  said  so ;  as  the  object  unquestionably  should  be  to  save  the 
child's  life;  but  this  should  surely  have  been  again  designated, 
especially  as  he  is  x\ow posting  up  the  points  of  practice.  More- 
over, it  appears  to  give  contradiction  to  the  cautions  and  distinc- 
tions he  had  just  made  before,  and  thus  sets  him  against  himself. 
For  just  above,  he  states:  "if  this  be  not  practicable,"  (return- 
ing the  cord,)  "and  the  pulsation  suffer,  or  the  circulation  be  en- 
dangered, we  must  accelerate  the  labour  by  the  forceps.  If  the  pul- 
sation be  stopped,  and  the  child  dead  when  we  examine,  then 
labour  may  be  allowed  to  go  on,  without  paying  any  attention  to 
the  cord."  p.  404.  Yet  a  few  lines  below,  we  find  the  ambiguous 
directions  we  have  just  quoted.  Dr.  Denman  is  much  more  pre- 
cise upon  this  subject;  he  observes  that  "when  the  head  of  the 
child  presents,  and  has  advanced  far  into  the  pelvis,  if  the  pains 
be  slow,  and  ineffectual,  and  the  child  living,  it  may  be  considered 
whether,  without  hazard  to  the  mother,  we  may  not  employ  the 
forceps  or  vectis;  and  by  extracting  the  head  sooner  than  there 
was  reason  to  think  it  xoould  he  expelled  by  natural  painsy 
preserve  the  child."     I  have  italicised  parts  of  Dr.  D.'s  direc- 


532  ON  PRESENTATIONS,  WITH  THE 

tions,  with  a  view  to  point  out  tlie  important  omissions,  in  those 
of  Mr.  Burns. 

1468. 1  would  without  hesitation  have  recourse  to  turning  under 
the  circumstances  just  stated,  and  the  ergot  had  failed;  (1449)  or 
if  the  forceps  were  not  at  hand,  or  within  timely  reach,  rather 
than  supinely  see  the  child  perish  ;  unless,  let  it  be  observed,  the 
waters  had  been  so  long  drained  off,  and  the  uterus  so  firmly 
contracted,  as  to  hold  out  no  prospect  of  success,  or  unless  the 
head  of  the  child  had  escaped  from  the  mouth  of  the  uterus:  I 
vvould  disregard  the  head  being  at  the  inferior  strait,  provided  it 
was  still  enclosed  in  the  uterus;  the  waters  not  too  long  expend- 
ed; and  the  head  easily  movable  in  the  pelvis.  For  I  agree  per- 
fectly with  Dr.  Denman  it  is  sometimes  best  to  go  beyond  the 
common  rules  of  art,  if  we  can  save  the  child  by  doing  so. 

1469.  5th.  "When  the  presentation  is  preternatural,  (that  is, 
agreeably  to  Mr.  Burns,  when  any  other  part  than  the  head 
presents,)  these  directions  are  to  be  attended  to,  and  the  practice 
is  also  to  be  regulated  by  the  general  rules  applicable  to  such  la- 
bours." 

1470.  I  have  stated  that  the  woman  may  be  delivered  with- 
out assistance,  when  either  the  head,  breech,  feet  or  knees,  pre- 
sent; but  confessed,  however,  that  the  head  is  certainly  the  most 
favourable  of  these  presentations.  I  have  laid  down  rules  for  the 
management  of  each  of  these  varieties  of  labour,  when  they  are, 
and  when  they  are  not,  complicated  by  accidents,  which  must 
constantly  be  kept  in  view  in  the  management  of  the  case  in 
which  the  cord  had  prolapsed,  of  which  we  are  now  speaking. 
Mr.  Burns'  last  direction  contains  just  principles,  and  are  worthy 
of  attention:  they  would  have  been  still  more  useful,  had  he  fol- 
lowed the  plan  of  Dr.  Denman,  by  specifying  the  particular 
treatment  of  preternatural  labours,  accompanied  by  a  falling  of 
the  cord. 

1471.  Dr.  Denman  says,  "when  there  is  a  descent  of  the  funis, 
with  a  preternatural  presentation  of  the  child,  our  conduct  must 
have  regard  to  both  these  circumstances." 

1472.  <<  Should  the  breech  present,  the  case  will  very  much 
resemble  the  presentation  of  the  head;  that  is,  the  same  methods 
for  replacing  the  cord  may  be  tried,  and  with  rather  a  better 
chance  of  success.  If  these  fail,  instead  of  considering  the  labour 
as  one  of  those  which  is  to  be  resigned  to  the  natural  efforts,  it 


FALLING  DOWN  OF  THE  UMBILICAL  CORD.  533 

may  be  expedient  at  a  proper  time  to  bring  down  one  or  both  of 
the  inferior  extremities,  taking  care  that  the  funis  be  not  entangled 
between  the  legs  of  the  infant." 

1473.  "  Should  the  arm  present,  and  such  presentation  be 
complicated  with  a  descent  of  the  funis,  very  little  difference  of 
conduct  will  be  required;  because,  in  the  first  place,  we  should 
determine  to  turn  the  child,  and  deliver  by  the  feet,  and  the  ad- 
ditional circumstance  of  the  descended  funis  can  require  nothing 
more  to  be  done.  Yet,  when  the  feet  of  the  child  are  brought 
down,  if  the  pulsation  of  the  funis  be  lively  or  perceptible,  it  may 
sometimes  admit  of  a  debate  whether  it  will  be  most  proper  to 
hasten  the  delivery,  especially,  if  the  os  uteri  be  not  sufficiently 
open;  or  to  leave  it  to  be  expelled  by  the  returning  pains.  In 
either  case  it  will  however  be  right,  to  attempt  to  return  the  funis 
within  the  uterus,  and  if  it  be  in  our  power,  out  of  the  way  of 
compression." 

1474.  Though  the  above  directions  are  perfectly  clear  and  well 
understood  by  the  experienced  practitioner,  they  are  far  from 
being  sufficiently  explicit  to  the  student  or  the  young  practitioner. 
I  would  cite  as  an  instance  of  the  deficiency  of  precision,  the  ex- 
pression, '<  it  may  be  expedient  at  a  proper  time  to  bring  down 
one  or  both  of  the  inferior  extremities."  How  would  the  unskill- 
ed know  when  the  proper  time  for  bringing  down  the  feet  had 
arrived?  For  the  measure  must  be  either  useful  or  worthless:  if 
useful,  the  uninformed  should  be  instructed  what  constituted  the 
proper  time,  that  advantage  might  be  taken  of  it;  if  worthless, 
it  should  not  have  been  named,  as  it  might  create  emban-assment. 
We  will  endeavour  to  supply  the  deficiency  of  Dr.  Denman  by 
stating,  that  the  proper  time  for  bringing  down  the  feet  when  the 
breech  presents,  especially  when  complicated  by  the  falling  of  the 
funis,  is, 

1st.  When  the  uterus  is  well  dilated,  and  the  external  parts 
well  disposed  to  relax. 

2d.  When  the  breech  does  not  descend  with  sufficient  rapidity, 
to  give  promise  that  the  coi'd  should  not  be  long  compressed. 

3d.  When  the  breech  is  ill-situated  as  regards  the  pelvis ;  (860) 
or  when  it  does  not  readily  engage  in  the  superior  strait. 

4th.  When  the  cord  is  likely  to  sufier,  or  is  actually  suffering 
compression,  and  the  child's  life  threatened,  if  not  speedily  re- 
lieved. 


534  ON  PRESENTATIONS,  &C. 

5th.  When  there  is  a  deficiency  or  the  absence  of  adequate 
pains. 

1475.  As  another  instance,  we  may  produce  the  caution,  "tak- 
ing care,  (in  bringing  dov/n  the  extremities,)  that  the  funis  be 
not  entangled  between  the  legs  of  the  infant."  In  suggesting  this 
caution,  Dr.  D.  shows  himself  thoroughly  well  acquainted  with  the 
contingencies  of  the  operation  of  bringing  down  the  feet;  a  contin- 
genc}^  that  has  too  often  defeated  the  object  of  interfering  with 
the  labour,  but  he  neglected  to  inform  the  inexperienced  practi- 
tioner how  this  was  to  be  avoided.  He  should  have  informed  his 
readers,  that  the  cord  would  most  probably  descend  on  one  of  the 
sides  of  the  pelvis;  and  (almost)  consequently,  vvould  be  found 
either  on  the  fore  or  hind  part  of  the  child.  If  on  the  fore  part, 
the  cord  should  be  carefully  carried  up  with  the  hand  that  is  in 
search  of  the  feet,  and  when  these  are  found,  the  cord  should  if 
possible  be  made  to  pass  over  them,  and  made  to  lie  above  the 
legs,  and  upon  the  belly  of  the  child,  which  will  certainly  pre- 
vent its  getting  between  these  extremities. 

1476.  If  it  descend  on  the  back  part  of  the  child,  it  should  be 
returned,  above  the  brim  of  the  pelvis,  by  the  hand  not  to  be 
employed  for  bringing  down  the  feet;  this  will  entirely  remove 
it  from  the  risk  of  its  becoming  entangled  between  the  legs.  (See 
rules  for  bringing  down  the  feet  in  the  breech  presentations,  S92, 
ct  seq.) 

1477.  If  it  descend  on  the  anterior,  or  posterior  portion  of  the 
pelvis,  the  cord  should  be  removed  to  one  of  the  sides  of  the  pel- 
vis; and  when  practicable  to  that  side  to  which  the  back  answers. 

1478.  If  it  should  be  found  to  descend  between  the  legs  of  the 
child,  the  feet  must  not  be  brought  down,  until  the  cord  has  been 
slipped  over  one  of  the  legs. 

1479.  If  it  be  judged  proper  to  use  the  forceps,  their  employ- 
ment must  be  subject  to  the  rules  which  govern  their  application; 
always  however  being  certain,  that  the  cord  is  not  interposed  be- 
tween the  blade  of  the  instrument,  and  the  head  of  the  child. 


535 


CHAPTER  XXXIX. 

OP  THE  EUJTUKE  OF  THE  UTERUS. 

1480.  During  labour,  the  uterus  every  now  and  then  is  rup- 
tured ;  and,  perhaps,  even  oftener  than  at  present  we  dare  assert 
— sometimes  this  accident  is  concealed  from  ignorance;  and  at 
others  from  design  ;  hence,  many  cases  must  occur  of  which  the 
])ublic  remains  uninformed.  Nothing  can  justify  the  concealment 
of  this  event,  though  we  can  promise  ourselves  but  little  by  the 
avowal ;  but  it  is  a  duty  we  ovvc  the  connections  of  the  unfortu- 
nate woman,  as  well  as  the  profession  itself.  Concealment  often 
arises  from  a  previously  adopted  theory  upon  this  subject ;  and 
the  supposed  risk  of  professional  reputation  ;  than  which,  nothing 
can  be  more  disingenuous,  or  hypothetical.  I  would,  in  one 
word,  recommend  in  all  such  cases,  its  most  speedy  avowal,  to 
those  immediately  concerned  in  the  event;  and  must  declare,  I 
should  consider  the  conti-ary  conduct,  as  highly  derogatory  to  the 
honourable  feelings  which  every  medical  practitioner  should  pos- 
sess ;  as  well  as  doing  serious  injur}^  to  the  advancement  of  ob- 
stetrical knowledge. 

1481.  In  treating  this  subject,  I  shall,  first,  consider  whether  it 
be  proper  to  attempt  anything  for  the  woman's  relief,  as  there  is 
much  authority  against  it ;  and  because  it  is  constantly  made  the 
plea,  for  the  concealment  of  this  accident ;  second,  I  shall  take 
into  view  the  variously  reputed  causes  of  it,  with  their  mode  of 
action  ;  third,  detail  the  symptoms  and  consequences  of  the  rup- 
ture ;  and  fourth,  indicate  the  mode  of  proceeding,  under  the 
various  circumstances  with  which  this  accident  may  be  compli- 
cated. 

1482.  Di'.  Hunter  considered  any  attempt  to  relieve  a  woman 
who  had  suffered  a  rupture  of  the  uterus,  as  cruel — therefore  it 
was  not  to  be  attempted.  This  ojnnion  was  afterwards  more 
strongly  enforced  by  the  late  Dr.  Denman,  who  declared,  that 
"  when  the  uterus  is  ruptured  at  the  time  of  labour,  both  reason 
and  experience  show,  that  the  patient  has  a  better  chance  of  re- 
covering, by  resigning  the  case  to  the  natural  efforts  of  the  con- 
stitution, than  by  any  operation,  or  interposition  of  art. " 


536  RUPTURE  OP  THE  UTERUS. 

1483.  I  consider  the  assertion  of  Dr.  Denman,  to  be  in  oppofsi- 
tion  both  to  ''reason  and  experience;"  to  reason,  because  it  would 
be  a  natural  suggestion,  that  that  woman's  chance  would  be  best, 
from  whom  many  of  the  causes  were  removed,  that  would  hinder 
recovery,  by  the  delivery  of  the  child,  &c.;  and  to  experience, 
because  we  have  the  most  unequivocal  proofs  of  recovery,  upon 
record,  where  "  the  interposition  of  art"  was  resorted  to. 

1484.  Thus  Heister,*  Douglass,!  Hamilton,^  Ross,§  Kitc,l| 
Madame  La  Chaple,ir  relate  cases  of  entire  recovery  after  the  de- 
livery of  the  child,  through  the  natural  passages  ;  while  Hamil- 
ton,** Thibault,tt  Lambron,J|  &c.  give  others  of  equal  success, 
where  gastrotomy  had  been  performed.     In  all  of  these,  however, 

-the  success  was  confined  to  the  mother  ;  the  child  was  uniformly 
dead — but  I  have  strong  reason  to  believe,  that  this  was  very 
much  owing  to  the  delay  which  took  place  before  the  operation 
was  performed.  Indeed  Burton§§  renders  this  almost  certain, 
by  the  relation  of  a  case  which  fell  under  his  notice  ;  in  this,  the 
child  was  delivered  alive,  though  the  mother  died  ;  while  Mr. 
Haden  relates  an  instance  of  the  preservation  of  both  mother  and 
child.lill 

1485.  Thus,  we  can  most  successfully  destroy  Dr.  Denman's 
celebrated  aphorism  on  the  subject  of  the  rupture  of  the  uterus,  by 
producing  cases,  in  which  the  "  interposition  of  art"  was  followed 
by  success.  This,  I  think,  should  put  the  matter  to  rest ;  espe- 
cially as  there  is  no  instance  extant,  at  least  with  which  I  am 
acquainted,  where  the  woman  recovered  at  the  full  period  of 

*  Instlt.  de  Chir.  torn.  II.  p.  137. 

f  Essay  on  Rupture  of  the  Uterus,  p.  7. 

+  Outlines,  p.  344.  MS.  Lectures. 

§  Annals  of  Med.  Vol.  III.  p.  377. 

II  Mem.  Med.  Soc.  Vol.IV.  p.  253. 

1  Annuaire  Med,  Chir.  torn.  I.  p.  542. 

**  MS.  Lectures. 

ft  Jour,  de  Med.  for  1768. 

%\  Baudelocque,  Vol.  HI.  p.  430. 

§§  Syst.  of  Mid.  §43,  p.  110. 

II II  Dr.  Davis  relates  a  case  of  the  rupture  of  the  anterior  portion  of  the  uterus 
from  which  the  patient  recovered  in  about  six  weeks.  In  this  case,  the  child 
was  delivered  by  the  craniotomy  forceps,  after  having  its  head  opened  by  Smel- 
lie's  scissors.  The  neck  of  the  bladder  was  so  severely  wounded,  from  its 
connection  with  the  portion  of  the  uterus  injured,  as  to  prevent  her  retaining 
her  urine  ever  after.  This  case,  tliough  unfortunate  as  regards  the  last  named 
injury,  is  nevei'theless  a  case  in  ])oint,  to  show  that  the  woman  may  recover 
after  the  uterus  has  been  lacerated. 


RUPTURE  OF  THE  UTERUS.  537 

utero-gestation,  when  the  child  was  permitted  to  remain  unde- 
livered. 

1486.  There  are  a  number  of  instances  upon  record,  which 
purport  to  be  recoveries,  after  the  rupture  of  the  uterus,  where 
the  foetus  was  permitted  to  remain  in  the  abdomen — but  they  are 
liable  to  a  strong  suspicion,  and  are  far  from  standing  the  test  of  ri- 
gorous examination;  they  appear  to  be  cases  of  extra-uterine  con- 
ceptions chiefly,  or  of  but  the  partial  rupture  of  the  uterus.  By 
partial  rupture,  Imecm,  where  the  muscular  substance  of  this  or- 
gan has  suffered  laceration^  but  where  the  ivound  does  not  pass 
through  its  peritoneal  coat.  Of  this  kind  are  the  cases  related  by 
a  writer  in  the  Jour,  de  Med.  for  1780,  also  those  by  Drs.  Bell 
and  Sims.*  Dissection  proved  in  several  of  these  cases,  that  the 
peritoneum  suffered  only  from  distention.  From  all  that  I  can 
learn  from  others,  or  my  own  experience,  I  cannot  see  any  reason 
for  withholding  aid  from  the  afflicted  woman,  who  may  have  suf- 
fered this  calamity — except,  indeed,  in  that  forlorn  condition  of 
the  patient,  where  she  would  die  before  aid  could  be  given.  But 
what  can  we  promise  ourselves,  by  not  attempting  delivery?  fori 
rnust  again  repeat,  that,  there  is  no  instance  of  recovery  at  full 
time,  from  a  rupture  of  the  uterus,  where  the  foetus  was  permit- 
ted to  remain  in  the  abdomen  of  the  mother — nor  should  the  opi- 
nions of  Dr.  Hunter,  Dr.  Denman,  and  Mr.  Burns,  be  considered 
sufficient  authority  in  such  cases  to  screen  from  reprehension,  any 
one  who  may  have  neglected  an  opportunity  to  discharge  what  I 
consider  his  bounden  duty,  by  delivering  his  patient  instantly,  if 
practicable,  when  she  has  suffered  a  laceration  of  the  uterus. 

1487.  Indeed,  the  objections  of  Dr.  Denman,  are  not  entitled 
to  the  smallest  weight  upon  this  point;  since  he  is  entirely  at  va- 
riance with  himself.  In  his  "  Introduction  to  Midwifery, "t  he  ap- 
peafs  to  have  entertained  rational  and  liberal  views  upon  this  sub- 
ject; he  there  tells  us,  that,  "beside  some  few  others,  (cases  of 
rupture,)  of  which  I  have  been  informed,  or  which  are  recorded, 
a  case  has  occurred  to  my  very  ivorthy,  able,  and  exjierienced 
friend  Dr.  Andrew  Douglass,  in  which  the  uterus  was  ruptured; 

he  turned  the  child,  the  patient  recovered,  and  had  afterwards 
children."     And  Dr.  Denman  observes  upon  this  case,  "  if  no 

*  See  Essays  on  Subjects  connected  with  Midwifery,  where  this  subject  is 
treated  at  large,  (p.  201.) 
t  Vol.  n.  p.  117. 
68 


538  RUPTURE  OF  THE  UTERUS. 

other  case  had  ever  occurred,  I  apprehend  this  would  be  sufficient 
authority  to  render  it  in  future,  the  indispensable  duty  of  every 
practitioner  to  act  in  a  similar  manner;  and  bad  as  the  chance 
is  of  the  patient,  to  be  strenuous  in  using  all  the  means  which  art 
dictates  to  extricate  her,  if  possible,  from  danger,  or  to  preserve 
the  child." 

1488.  Dr.  Denman  has  by  no  means  satisfied  me,  or  perhaps 
any  one,  why  his  sentiments  underwent  a  change  upon  this  sub- 
ject; and  the  more  especially,  as  it  is  a  change  to  be  considered  as 
imfriendly  to  the  cause  of  science,  and  to  the  interests  of  humanity 
— it  seems  he  has  drawn  a  conclusion  upon  this  point,  that  satis- 
fied himself;  though  totally  gratuitous,  in  the  estimation  of  every 
body  else;  namely,  "  that  there  are  more  instances  upon  record  of 
recoveries  of  women  who  have  not  been  delivered,  than  those  who 
have  been  delivered  after  rupture  of  the  uterus." 

1489.  Were  this  position  of  Dr.  Denman  really  founded  in  fact, 
it  would  deserve  the  most  serious  consideration;  but  as  strong 
doubts  must  be  entertained  upon  this  point,  it  has  not  changed  my 
opinion;  first,  because  the  subjects  of  comparison  are  not  equal; 
as  very  many  more  women  have  been  suffered  to  remain  unde- 
livered after  rupture,  than  have  been  delivered;  consequently  a 
conclusion  cannot  legitimately  be  drawn;  as  the  proportions  they 
bear  to  each  other  cannot  be  known;  second,  because  I  deny  that 
there  is  a  well-attested  instance  of  the  woman's  recovery,  when 
she  was  permitted  to  remain  undelivered. 

1490.  From  all  I  can  collect  from  tiie  histories  of  cases  of  rup- 
tured uteri,  it  would  appear,  that  life  is  prolonged  and  suffering 
abated,  by  delivery;*  it  therefore  involves  a  great  moral  question; 
and  if  the  facts  be  as  I  have  stated,  and  as  I  most  seriously  be- 
lieve them  to  be,  it  must  resolve  itself  into  inculcating  it  as  an 
obligation,  that  we  deliver  whenever  practicable,  after  the  uterus 
has  suffered  laceration. 

1491.  Upon  a  comparison  of  an  equal  number  of  cases  deliver- 
ed after  rupture,  with  those  not  delivered,  it  was  found,  that  the 
women  who  were  delivered,  lived  much  longer  on  the  average, 
than  those  who  were  not  delivered;  now,  if  death  caw  be  suspend- 
ed by  our  efforts,  even  for  a  short  time,  it  will  follow,  it  becomes 
a  duty  to  make  them;  and,  if  we  add  to  this,  what  we  have  very 
confidently  asserted,  that  there  is  no  instance  of  recovery  where 

*  See  Essays  on  various  subjects  connected  with  Midwifery,  by  the  author, 
p.  227. 


RUPTURE  OF  THE  UTERUS.  539 

delivery  has  not  been  performed,  this  first  part  of  my  inquiry 
must  be  terminated  by  declaring,  it  is  almost  always  proper  to 
interpose  art,  in  cases  of  ruptured  uteri. 

1492.  Very  many  causes  are  assigned  for  the  rupture  of  the 
uterus;  some  of  which  appear  totally  incompetent  to  this  end; 
while  others  of  powerful  agency,  are  but  slightly  glanced  at.  La 
Motte  believed  that  the  struggles  of  the  child  were  capable 
of  this  accident;  hence,  by  him,  they  are  enumerated  as  a  cause. 
In  this  he  has  been  followed  by  Leveret  and  Crantz — indeed  I 
may  say  some  late  writers.  But  the  child  is  almost  always  pas- 
sive when  the  accident  happens;*  and  1  may  add  in  proof  of  this, 
that  the  uterus  has  given  way,  after  the  death  of  the  child. 

1493.  Dr.  Dcnmant  says,  "  the  uterus  may,  independently  of 
disease,  be  mechanically  worn  through  in  long  and  severe  labours, 
by  pressure  and  attrition  between  the  head  of  the  child,  and  the 
projecting  bones  of  a  distorted  pelvis;  especially,  if  they  be  drawn 
"into  points  or  a  sliarp  edge."  To  this  doctrine  I  cannot  subscribe; 
first,  because,  before  the  membranes  are  ruptured,  the  head  can- 
not rest  with  sufficient  firmness  against  any  given  point  to  produce 
the  necessary  degree  of  "attrition;"  second,  that  after  the  evacu- 
ation of  the  waters,  the  body  of  the  child  is  so  firmly  embraced 
by  the  contracting  uterus,  that  "attrition"  cannot  take  place;  third, 
there  could  not  be  sufficient  friction  generated  between  the  smooth 
surfaces  of  the  child's  head  and  the  uterus  to  produce  It;  fourth, 
in  such  cases  the  child's  head  should  also  exhibit  marks  of  this 
"attrition,"  yet  of  this  no  mention  is  ever  made. 

1494.  Salmathus,  agreeably  to  Mr.  Burns,  considers  a  "thin- 
ness" of  the  uterus  as  a  predisposing  cause  of  rupture — but  we 
have  no  evidence  in  any  case  whatever  of  this  "  thinness"  exist- 
ing as  an  original  conformation  of  the  uterus  before  the  rupture 
takes  place — if  it  be  found  thin,  (post  mortem,)  it  may  be  occa- 
sioned from  mere,  exhaustion  of  blood,  and  not  be  an  original 
condition  of  this  organ.  Mental  agitation  and  frights  are  also 
said  to  occasion  rupture  of  the  uterus;  but  strong  doubts  should 
be  entertained  of  such  causes. 

1495.  I  shall,  therefore,  pass  without  notice  many  causes  repu- 
ted as  capable  of  causing  this  accident;  and  consider  only  such, 

•  Baudelocque. 

f  Introduction,  p.  105. 


540  KUPTURE  OF  THE  TTTKUUS. 

of  whose  agency  no  reasonable  doubts  can  be  entertained.  I  shall 
divide  these;  first,  into  those  whicii  act  directly  upon  the  uterus; 
and  second,  into  those  which  have  an  indirect  influence. 

1496.  The  first  may  be  considered  mechanical  violences;  and 
may  be  both  external  and  internal.  The  external  may  be  blows, 
kicks,  or  violent  pressure;  the  internal  may  be,  ill-conducted  at- 
tempts to  turn  the  child;  the  attempt  to  return  a  prolapsed  limb; 
the  mal-adroit  use  of  instruments ;  or  the  unequal  surface  of  the 
child  itself. 

1497.  The  second,  or  indirect,  are  such  causes  as  may  have  a 
tendency  to  injure  the  continuity  of  the  uterus  by  mechanically 
impeding  the  passage  of  the  child;  as  a  contracted  pelvis;  an  un- 
usual sharpness  in  the  linea  ilio-pectinea;  exostoses,  tumours, 
scirrhi,  and  ulcers. 

1498.  The  action  of  these  two  sets  of  causes  are  different;  the 
first  act  directly,  by  exerting  a  force  beyond  the  resisting  power 
of  the  uterus;  the  second,  by  diminishing  the  strength  o(  apar- 
ticular  jiortion  of  this  viscus,  so  that  its  own  contraction  may 
be  sufficient  to  overcome  the  resistance  which  this  weakened  part 
offers. 

1499.  The  mode  in  which  the  first  set  of  causes  acts,  is  suffici- 
ently obvious  without  farther  explanation.  The  second  is  not  so 
clear,  yet  of  most  easy  explanation.  The  head  of  the  child,  co- 
vered by  the  uterus  on  all  sides,  cannot,  in  a  contracted  pelvis, 
readily  engage  in  the  opening  of  the  superior  strait;  it  must, 
therefore,  rest  for  a  long  time  stationary,  or  nearly  so,  at  its  mar- 
gin— if  this  be  sharp,  or  projecting,  the  uterus  will  suffer  in  pro- 
portion to  the  weight  of  the  child,  the  force  of  the  contractions 
of  the  uterus,  and  the  period  it  may  suffer  this  compression — in- 
flammation ensues ;  and,  if  the  cause  be  not  soon  removed,  gan- 
grene will  follow;  when  the  uterus  is  thus  weakened,  it  will  be 
easil}?^  understood  how  a  small  force  may  ruptitre  it. 

1500.  The  second  set  of  causes  acts  by  preventing  a  regular  de- 
velopement  of  the  different  portions  of  the  uterus  during  preg- 
nancy ;  consequently,  one  portion  or  other  is  put  unduly  upon 
the  stretch,  and  of  course  weakened;  and  by  its  remaining  pas- 
sive during  labour,  by  being  diseased,  it  cannot  resist  the  efforts  of 
the  healthy  portions.  When  the  action  of  the  uterus  itself  is 
the  cause  of  the  rupture,  it  always  takes  place  at  the  moment  of 
the  greatest  severity  of  pain.  Boer  and  other  German  Pathologists 
have  rendered  it  probable,  that,  that  peculiar  condition  of  the 


RUPTURE  OF  THK  UTERUS.  541 

uterus  called  "  Softening,"  may  be  a  cause  of  the  rupture  of  this 
organ  ;  for  though  it  is  never  perhaps  absolutely  until  after  death, 
yet  it  is  rendered  probable  that  it  may  exist  during  pregnancy, 
though  perhaps  in  an  inferior  degree  to  what  is  observed  in  post 
mortem  examinations,  yet  to  a  sufficient  extent  to  cause  rupture 
during  labour;  and  this  may  also  agreeably  to  the  same  authority 
be  the  cause  of  the  death  of  the  foetus  in  the  last  period  of  utero- 
gestation. 

1501.  Rupture  ma}^  happen  to  any  portion  of  the  uterus;  or  in 
any  direction;  or  at  its  connection  with  the  vagina — it  maybe 
more  or  less  extensive;  and  the  child  with  its  appurtenances  may 
pass  entirely,  or  partially,  into  the  abdominal  cavity. 

1502.  When  this  accident  happens,  it  almost  always  declares 
itself  by  such  symptoms  as  cannot  well  be  mistaken.  I  shall  now 
consider  those  symptoms,  under  the  third  division  of  our  subject. 

1503.  Crantz,  Levret,  and  others,  have  supposed  that  the  rup- 
ture of  the  uterus  might  be  foretold  by  premonitory  symptoms ; 
but  I  am  very  certain  that  few  things  can  be  more  equivocal  than 
the  symptoms  pointed  out  by  Crantz;  namely,  that,  "when  a 
woman  is  threatened  with  a  rupture  of  the  uterus  in  a  laborious 
labour,  the  belly  is  very  prominent  and  tight;  the  vagina  length- 
ened, and  the  orifice  of  the  uterus  very  high;  the  pains  are  strong, 
leave  little  interval,  and  do  not  advance  delivery."  I  have  seen 
all  these  symptoms  in  their  most  exalted  form,  without  the  labour 
terminating  by  rupture;  and  in  Mrs.  M's  case,  which  fell  under 
my  notice,  and  of  which  I  have  given  a  detail,*  "strong  pain 
with  little  interval"  were  not  among  its  precursors;  though  a 
very  extensive  laceration  of  the  uterus  took  place.  M.  Levret 
has  added  to  these  symptoms,  but  without  increasing  their  cer- 
tainty, "that  the  pain  the  woman  suffers,  is  always  seated  to- 
wards the  middle  of  the  epigastric  region;  that  a  last  effort  or  vio- 
lent leap,  succeeds  to  the  repeated  strugglings  of  the  child,  which 
announces  its  death  and  the  rupture  of  the  uterus." 

1504.  Did  the  signs  just  detailed,  portend  a  rupture  of  the 
uterus,  every  laborious  labour  would  be  threatened  with  one — 
every  symptom  enumerated  above,  is  almost  the  necessary  eflect 
of  the  tonic  action  of  the  uterus,  after  the  evacuation  of  the  wa- 
ters ;  yet  fortunately  for  suffering  woman,  this  accident  is  of  com- 
paratively rare  occurrence. 

*  See  Essays  on  various  Subjects  connected  witli  Midwifery,  by  the  Author, 
p.  238. 


542  RUPTURE  or  the  uterus. 

1505.  The  signs  added  by  Levret  are  frequently  witnessed, 
without  a  rupture  supervening:  and  it  has  occurred,  where  these 
marks  were  absent — it  is  also  well  known,  that  the  uterus  has 
given  way  after  the  death  of  the  child;*  I  therefore  perfectly 
agree  with  Baudelocque,  "  that  the  rupture  of  the  uterus  has  often 
taken  place  without  iDeing  preceded  by  any  of  them,  and  has  not 
happened  in  other  cases  where  their  union  declared  it  inevitable." 
The  conclusion  from  this  must  be,  that  it  would  be  extremely 
hazardous  to  act  upon  the  presumption,  that  a  rupture  of  the  ute- 
rus was  about  to  take  place,  because  of  the  presence  of  several  of 
the  symptoms  just  mentioned — who  could  justify  the  employment 
of  the  forceps,  or  crotchet,  or  perform  the  difficult  and  oftentimes 
dangerous  operation  of  turning,  upon  a  mere  surmise  that  this  ac- 
cident might  take  place? 

1506.  I  have  said  enough,  I  trust,  upon  the  uncertainty  of  any 
sign  or  signs  that  would  announce  a  rupture  to  be  at  hand;  I  shall 
therefore  pass  to  the  enumeration  of  the  symptoms  which  declare 
it,  after  it  has  taken  place: 

1507.  The  woman  feels  for  the  most  part,  an  acute  pain  at  the 
place  at  which  the  rent  happened — she  generally  cries  out,  and 
declares  that  something  terrible  has  happened  within  her — the 
rupture  is  said  sometimes  to  be  accompanied  by  a  noise  which  has 
been  distinguished  by  the  bystanders — a  discharge  of  blood  of 
greater  or  less  extent  takes  place  from  the  vagina — her  face  be- 
comes cold  and  pale — her  respiration  hurried — she  is  sick  at  sto- 
mach, and  most  frequently  vomits — the  matter  discharged  is 
sometimes  the  common  contents  of  the  stomach,  at  other  times  it 
consists  of  a  very  dark,  even  black-coloured  substance,  resembling 
coffee-grounds— the  pulse  is  extremely  frequent,  small,  flutter- 
ing, or  extinct — she  complains  of  a  mist  before  her  eyes,  loss  of 
sight,  and  extreme  faintness — a  cold  clammy  sweat  bedews  the 
surface  of  the  whole  body,  and  if  not  speedily  relieved,  convul- 
sions and  death  follow. 

1508.  These  symptoms  are,  however,  modified  by  several  cir- 
cumstances; 1st,  whether  it  be  the  uterus  itself,  or  its  connection 
with  the  vagina,  that  may  be  ruptured;  2d,  whether  the  child  has 
escaped  in  part  or  entirely  into  the  cavity  of  the  abdomen;  3d, 
whether  the  lesion  has  passed  through  the  substance  of  the  uterus 
alone,  or  has  penetrated  the  peritoneum. 

*  Annals  of  Med.  Vol.  III.  p.  293.  303. 


RUPTUHE  OF  THE  UTEKUS.  543 

1509.  1.  When  the  rupture  has  taken  place  either  in  the  body 
or  neck  of  the  uterus,  the  ])ains  either  cease,  or  slacken  so  much 
as  not  to  propel  the  child  if  it  be  still  retained  within  the  uterus. 

1510.  2.  When  the  child  escapes  entirely  into  the  cavity  of  the 
abdomen,  through  the  torn  uterus,  the  most  distressing  and  alarm- 
ing symptoms  quickly  follow — if  but  partially  protruded,  pain 
may  effect  the  delivery  of  the  child,  or  it  may  be  extracted  by 
art. 

1511.  3.  Should  the  wound  stop  at  the  peritoneal  covering  of 
the  uterus,  and  not  penetrate  the  abdomen,  there  is  reason  to  be- 
lieve that  the  symptoms  will  not  only  be  milder,  but  the  chance 
of  recovery  increased. 

1512.  However  strongly  and  decidedly  marked  the  symptoms 
which  accompany  rupture  may  be,  they  are  not  exclusively  to  be 
relied  on — but  when  they  have  excited  suspicion,  by  their  seve- 
rity and  character,  we  should  lose  no  time,  before  we  ascertain 
it — this  is  to  be  done  by  a  careful  examination  of  the  abdomen 
and  the  uterus;  the  first  by  the  application  of  the  hand  externally; 
and  the  other  by  the  finger  or  hand  per  vaginam.  Should  the 
accident  occur  before  the  rupture  of  the  membranes,  the  tumour 
which  they  formed  will  shrink  away;  for,  if  the  rent  be  through 
to  the  abdomen,  it  is  more  than  probable  that  the  membranes  will 
give  way,  and  the  waters  be  discharged  within  it;  but  should  the 
lesion  stop  at  the  peritoneum,  they  may  remain  entire  for  some 
time,  though  they  may  not  again  form  a  bag  within  the  circle  of 
the  OS  uteri. 

1513.  When  the  abdomen  is  examined  externally  by  the  hands, 
the  foetus,  if  the  rupture  be  complete,  may  readily  be  distinguished 
through  its  parietes;  if  the  foetus  cannot  be  thus  detected,  it  is 
presumable  that  it  has  not  escaped  entirely  from  the  uterus — but  we 
are  to  ascertain  this  by  a  careful  and  more  extensive  examination. 

1514.  If  the  accident  take  place  after  the  discharge  of  the  wa- 
ters, the  presenting  part  will  either  recede  beyond  the  reach  of 
the  finger,  or  can  be  easily  forced  back  by  its  pressure,  (pro- 
vided the  head  or  presenting  part  has  not  already  engaged  in  the 
pelvis) — if  the  former  obtain,  the  hand  should  be  introduced,  and 
the  nature  of  the  case  clearly  ascertained — should  the  os  uteri  be 
well  dilated  or  easily  dilatable,  the  hand  should  be  passed  into  the 
cavity  of  the  uterus,  so  that  the  extent  of  injury  be  well  under- 
stood. But  should  the  os  uteri  be  firmly  contracted,  so  as  to  refuse 
admission  to  the  hand,  without  the  application  of  much  farce,  the 


544  RUPTURE  OF  THE  UTERUS. 

point  should  be  given  up;  for  nothing  can  justify  a  violent  entry 
into  the  cavity  of  the  uterus. 

1515.  When  the  laceration  takes  place  at  the  neck  of  the  ute- 
rus, or  at  its  union  with  the  vagina,  the  child,  with  its  appurte- 
nances, almost  always  pass  into  the  cavity  of  the  abdomen;  in 
either  of  these  cases,  the  presenting  part  will  immediately  remove 
itself  from  the  superior  strait;  when  this  happens,  we  should,  as 
quickly  as  possible,  ascertain  whether  the  accident  has  taken 
place,  of  which  this  circumstance  would  instantly  give  the  suspi- 
cion. In  cases  like  these,  the  examinations  to  this  effect  are  more 
easily  conducted,  than  when  the  body  or  fundus  is  the  subject  of 
the  laceration;  as  the  parts  involved  in  the  mischief,  cannot  con- 
tract like  the  uterus  itself — the  uterus,  under  such  circumstances, 
will  be  found,  for  the  most  part,  firmly  contracted  either  on  the 
posterior  or  anterior  portion  of  the  pelvis,  as  it  may  happen  to  be 
the  posterior,  or  anterior  portion  of  the  vaginal  circle,  that  may 
have  sustained  the  injury — the  intestines  will  frequently  prolapse 
through  the  wound,  which  removes  at  once  all  doubt  as  to  the  na- 
ture of  the  accident — it  is  almost  needless  to  suggest  the  propriety 
of  a  cautious  and  gentle  examination,  after  the  hand  has  entered 
the  abdomen. 

1516.  When  the  nature  of  the  accident  is  ascertained,  it  be- 
hoves us  immediately  to  atttempt  the  relief  of  the  unfortunate  wo- 
man; and  the  means  for  this  purpose  are — first,  to  attempt  deli- 
very per  vias  naturales;  and  second,  to  perform  the  operation  of 
gastrotomy. 

1517.  We  may  perform  the  first,  whenever  the  neck,  or  its 
union  with  the  vagina  is  the  seat  of  laceration,  provided  the  pelvis 
is  of  a  good  conformation,  and  the  child  has  escaped  into  the  cavity 
of  the  abdomen — the  feet  of  the  child  should  be  sought  for,  and 
the  delivery  accomplished  as  in  a  case  of  turning — but  should  the 
pelvis  be  so  contracted  as  not  to  permit  the  child's  head  to  pass, 
this  mode  of  delivery  must  be  changed  for  the  second.  Should  but 
a  portion  only  of  the  child  have  escaped  through  the  rent,  and  the 
head  be  engaged  in  the  pelvis,  the  forceps  should  be  used,  or  if 
we  are  certain  of  the  child's  death,  the  crotchet  may  be  employed. 

1518.  When  either  the  body  or  fundus,  or  both,  have  suffered, 
and  the  child  has  escaped  into  the  abdomen,  the  delivery  per  vias 
naturales  may  be  either  difficult  or  impossible,  even  in  a  well- 
formed  pelvis;  for  the  uterus  will  most  probably  contract  itself  so 
much  as  to  render  the  re-passage  of  the  child  impracticable;  the 


RUPTURE  OF  THE  UTERUS.  545 

only  chance,  in  this  case,  is  the  immediate  performance  of  gastro- 
tomy;  should  a  contracted  pelvis  complicate  tliis  case,  the  latter 
operation  is  the  only  alternative.  But  should  the  uterus  remain 
flaccid,  and  its  mouth  yielding,  and  the  pelvis  well-formed,  we 
may  succeed,  though  with  difficulty,  through  the  natural  passages 
— but  if  this  flaccid  state  of  the  uterus  be  attended  by  a  deformed 
pelvis,  the  abdominal  section  is  the  resource. 

1519.  Should  the  vagina  alone  sufier,  and  the  child  pass  into 
the  abdomen,  we  should  deliver  by  the  natural  passages,  provided 
the  condition  of  the  pelvis  will  permit:  if  it  should  not,  gastro- 
tomy  must  be  had  recourse  to.* 

1520.  The  operation  of  gastrotomy,  I  believe,  is  one  which 
has  never  been  performed  in  this  country  on  the  living  subject, 
for  rupture  of  the  uterus;  but  there  is  no  reason  why  it  should 
not,  when  circumstances  are  sufficiently  imperious — we  have  the 
experience  of  the  European  surgeons  in  its  favour;  and,  however 
appalling  it  may  appear,  when  viewed  merely  as  an  operation,  it 
nevertheless  would  seem  to  add  but  very  little  additional  suffer- 
ing to  the  unhappy  woman.t 

1521.  But  to  derive  advantage  from  this  operation,  "  it  should 
be  performed  as  quickly  after  the  accident  as  possible,  while  the 
patient  still  retains  strength;  and  the  incision  should  always  be 
made  on  the  side  of  the  abdomen,  which  corresponds  with  the 
rupture  of  the  uterus,"^  if  practicable,  or  I  may  add,  if  that  side 
can  be  detected.  Should  either  the  anterior,  or  posterior  portion 
of  the  uterus  have  yielded,  the  child  would  most  probably  be  in 
the  middle  of  the  abdomen,  (provided  the  woman  had  not  changed 
her  position  after  the  accident,)  in  which  case  the  incision  would 
perhaps  be  best  made  in  the  linea  alba,  as  if  the  Cesarean  sec- 
tion were  about  to  be  performed. 

1522.  As  every  case  must  necessarily  be  interesting,  as  well  as 
instructive,  in  which  bold  and  judicious  operations  have  saved 
life,  I  will  relate  some  instances  of  success,  tbllowing  the  opera- 
tion of  gastrotomy. 

Gastrotomy. 

1523.  Dr.  L.  Frank  relates  the  following  interesting,  though 

»  The  reader,  if  he  wish  to  see  this  subject  more  amply  treated,  may  find  it  in 
«  Essays  on  various  Subjects  connected  with  Midwifery,"  by  the  Author,  p.  '201. 
t  Thibault  des  Bois,  Joui*.  de  Med.  for  1768. 
t  Path.  Chimr.tom.  II.  p.  239,  par.  M.  Lussus. 
69 


546  RUPTURE  OP  THE  UTERUS. 

rather  too  generally  described  case,   in  which  g.istrotomy  was 
successfully  performed: 

1524.  "Angela  Grossi,  of  Parma,  aged  forty-four,  had  borne 
five  children,  and  had  reached  the  ninth  month  of  her  sixth  preg- 
nancy, without  the  occurrence  of  any  accident.  On  the  morning 
of  the  9th  of  August,  1817,  labour  commenced;  and  whilst  stand- 
ing up,  she  was  seized  with  a  faintness,  accompanied  by  vomit- 
ing. She  was  therefore  placed  on  her  bed,  by  the  assistance  of 
her  husband  and  midwife.  At  that  moment,  she  stated  that  she 
experienced  a  feeling  of  laceration  in  the  abdomen,  and  also  a 
sensation  of  there  being  two  children.  A  surgeon,  who  was 
called  in,  asserted  that  the  effort  of  vomiting  had  carried  the 
child  upwards;  adding,  that  another  migiit  propel  it  downwards; 
and  advised  the  patient  to  remain  quiet." 

1525.  "The  midwife,  however,  remarking  that  the  abdomen 
swelled,  that  the  vomiting  did  not  cease,  and  that  the  breathing 
became  irregular,  called  in  Dr.  G.  Rossi.  On  examination,  he 
detected  a  rupture  of  the  uterus;  and  on  consultation  with  his 
father,  and  other  medical  men,  it  was  unanimously  resolved,  to 
have  recourse  to  gastrotomy." 

1526.  "Two  hours  after  the  occurrence  of  the  accident,  the 
operation  was  performed  by  Professor  Cecconi,  in  the  left  hypo- 
gastric region,  precisely  at  the  point  where  the  feet  of  the  child 
were  felt.  When  the  incision  was  made,  the  child  presented 
with  the  feet,  and  was  extracted  alive,  together  with  the  secun- 
dines.  No  bad  symptoms  are  alluded  to,  and  it  is  stated  that 
the  patient  was  perfectly  recovered  forty  days  after  the  opera- 
tion. Three  years  afterwards,  she  had  a  seven  months'  child, 
which  lived  a  fortnight.  After  her  recovery,  a  ventral  hernia 
presented  itself  in  the  situation  of  the  cicatrix,  which,  though  ir- 
remediable, was  not  productive  of  much  inconvenience."* 

1527.  In  Germany  the  operation  of  gastrotomy  has  been  per- 
formed with  success,  by  Mr.  Bulk,  upon  a  woman  of  good  con- 
stitution, and  of  thirty-six  years  of  age.  The  patient  during  her 
pregnancy,  suffered  from  a  severe  pain  in  the  left  and  inferior 
side  of  the  abdomen;  her  menses  were  not  suppressed;  and  every 
six  or  eight  days  a  clot  of  blood  and  mucus  came  away  from  the 
vagina.     Her  general  health  was  good. 

1528.  About  the  middle  of  the  eighth  month,  v/hile  she  was 

*  Anderson's  Uuurtcrly  Journal,  Vol.  II.  No.  1,  for  Oct.  1825. 


RUPTURE  OF  THE  UTERUS.  547 

washing  some  linen,  she  suddenly  felt  as  if  sonaething  was  tearing 
in  her  abdomen;  at  the  same  time,  a  swelling  of  the  size  of  two 
fists,  (poins,)  formed  in  the  right  side  below  the  umbilicfis.  She 
fainted;  and  during  six  weeks  she  suffered  dull  pains  in  the  abdo 
men.  At  this  time  she  had  true  labour  pains  for  forty-eight  hours, 
and  was  attended  by  a  midwife.  The  os  uteri  dilated  so  little  as 
to  admit  but  one  finger.  The  tumour  disappeared  during  these 
pains.  The  patient  recovered,  with  the  size  of  the  abdomen  un- 
diminished. 

1529.  In  this  condition  she  continued  for  two  years  and  three 
months,  menstruating  regularly.  She  became  again  pregnant, 
and  suffered  but  little  inconvenience  until  the  seventh  month; 
when  her  abdomen  became  painfully  distended,  and  of  a  bluish 
colour;  fluctuation  was  induced  on  the  least  motion.  At  the  full 
period,  she  was  delivered  of  a  large  foetus,  which  she  suckled  for 
fifteen  days;  the  infant  then  dying  of  an  aphthous  affection.    . 

1530.  The  milk  ceasing  to  be  secreted,  she  declined  rapidly 
with  hectic  symptoms;  the  tumour  re-appeared  below  the  umbi- 
licus, of  about  the  size  of  an  egg;  it  soon  opened,  and  discharged 
pus  from  small  orifices.  The  patient's  constitution  was  rapidly 
yielding,  and  gastrotomy  was  immediately  performed.  An  incision 
was  made  with  usual  precaution  through  the  linea  alba  into  the 
cavity  of  the  abdomen,  from  two  and  a  half  inches  above  the  um- 
bilicus, to  within  nine  lines  of  the  pubis;  care  being  taken  to  con- 
fine the  intestines.  A  foetus  of  full  size,  in  which  putrefaction 
had  commenced,  was  found  on  the  right  side  of  the  uterus.  ''  I 
raised,"  says  the  operator,  "  the  body  with  much  care,  and  en- 
deavoured to  trace  the  umbilical  cord.  This  was  turned  over  the 
uterus  to  the  left  side,  and  termanated  in  a  vascular  substance  in 
state  of  suppuration,  (probably  the  remains  of  the  placenta,)  which 
was  situated  below  the  great  omentum.  I  pressed  out  and  dried 
up,  by  means  of  a  sponge,  the  pus  which  covered  these  parts. 
The  uterus  was  an  inch  and  a  half  in  length,  and  an  inch  in 
breadth,  of  a  pale  rose-colour,  and  could  easily  be  distended,  (se 
laiss  ait  distendre  aisement,)  it  was  otherwise  in  a  good  condition. 

1531.  The  wound  in  the  abdomen  was  closed  by  sutures.  The 
patient  was  in  great  danger  from  inflammatory  symptoms  for 
eight  days;  but  eventually  she  recovered.  She  left  her  bed  on 
the  fifty-fifth  day. 


PART  IV. 


ON  DELIVERIES  PERFORMED  BY  CUTTING   INSTRUMENTS,   AP- 
PLIED EITHER  TO  THE  CHILD  OR  MOTHER. 

1532.  Hitherto  I  have  been  treating  of  labours  which  could 
be  terminated  by  the  natural  agents  of  delivery;  those  in  which 
the  hand  alone  could  perform  it;  and  those  in  which  it  was  ne- 
cessary and  proper  to  employ  such  instruments  as  were  calculated 
to  preserve  both  mother  and  child.  I  have  now  to  consider  those 
unfortunate  instances,  in  which  the  labour  is  impracticable  with- 
out either  mutilating  the  child,  or  subjecting  the  woman  to  the 
Cae^rean  section,  or  the  section  of  the  ossa  pubis,  commonly 
called  the  Sigaultean  operation. 

1533.  There  are  a  number  of  causes  which  may  place  an  un- 
fortunate woman  in  the  predicament  of  having  .her  child  mutilat- 
ed, or  force  her  to  submit  to  the  alternatives  just  mentioned. 
These  causes  are,  1st.  A  deformity  of  the  pelvis;  2d.  A  defor- 
mity of  the  child,  or  its  monstrosity?  3d.  Accidental  deformity, 
as  hydrocephalus,  dropsy  of  the  abdomen,  &c. 


CHAPTER  XL. 


I.     DEFORMITY  OF  TKE  PELVIS. 


1534.  This  subject  has  already  been  treated  of;  (45,  &c.)  but 
it  was  then  mentioned  as  a  mere  deviation  from  the  healthy  mea- 
surement of  the  pelvis:  I  shall  now  consider  the  indications  this 
unhealthy  structure  may  produce.  When  the  deviations  are  but 
small,  a  child  may  be  delivered  alive  at  full  time;  but  the  la- 
bour will  be  more  tedious  and  painful,  if  the  child  be  of  the  or- 
dinary size,  than  if  the  pelvis  enjoyed  its  full  and  proper  pro- 
portions.    But  the  variations  may  be  greater,  or  even  at  times 


OF  TURNING  IN  A  DEFORMED  PELVIS.  549 

excessive— the  degree,  therefore,  will  necessarily  give  rise  to  va- 
rious modes  of  terminating  the  labour  by  artificial  means. 

1535.  The  resources  of   art  under    deformities  of  pelvis, 
are, 

a.  Turning. 

b.  Forceps. 

c.  Cephalotomy. 

d.  Cesarean  operation. 

e.  Premature  delivery. 

f.  Section  of  the  pubes. 

g.  Regimen  during  pregnancy. 

Sect.  I. — a.  Of  Turnings  in  a  Deformed  jjelvis,  as  a  Means 
of  saving  the  C/iikPs  Life. 

1536.  When  treating  of  this  operation  professedly,  I  took  oc- 
casion to  observe,  (736)  that  it  was  always  one  of  hazard  to  the 
child,  even  in  a  well-constructed  pelvis;  a  fortiori,  the  risk 
must  be  greater  in  a  contracted  one.  For  this  operation  to  be 
successful,  even  under  the  best  management,  it  will  require,  1st. 
That  there  shall  exist  a  proper  relation  between  the  diameters 
of  the  child's  head,  and  those  of  the  pelvis;  2d.  That  the  waters 
shall  not  have  been  too  long  drained  off;  3d.  That  the  breast  of  the 
child,  and  cord,  shall  not  suffer  compression  ;  4th.  That  the  head 
shall  not  be  too  long  detained  in  the  pelvis ;  and  5th.  That  the 
neck  of  the  child  shall  not  suffer  too  much  extension  after  the 
body  is  delivered. 

1537.  To  obtain  these  advantages,  requires  no  common  com- 
bination of  favourable  circumstjinces;  and  as  these  for  the  most 
part  must  necessarily  be  contingent,  it  is  no  way  surprising,  that 
this  operation  should  so  often  fail  of  success — and  to  all  that  may 
be  required  on  the  part  of  the  mother  and  child  to  render  it  even 
probably  safe,  there  must  be  added  skill  on  the  part  of  the  opera- 
tor; for,  without  this,  very  often  the  child  would  perish,  though 
the  case  may  have  been  the  most  proper,  or  most  easy  of  per- 
formance. 

1538.  Should  the  deformity  then,  leave  less  than  three  inches 
and  a  half  in  the  antero-posterior  diameter  of  the  superior  strait, 
we  need  scarcely  look  to  this  operation  for  success,  as  regards 
the  child  ;  and  when  resorted  to  under  such  circumstances,  it 
must  only  be  considered  as  a  remedy  for  the  safety  of  the  mo- 


550  OF  TURNING  IN  A  DEFORMEn  PELVIS. 

ther.  In  this  country,  indeed,  even  the  diameter  just  specified, 
would  rarely  be  suflTicient  to  give  promise  of  success,  under  the 
best  and  most  skilful  management ;  for  the  transverse  diameter 
of  the  head  of  the  greater  part  of  the  children  born  at  full  time, 
would  exceed  three  inches  and  a  half;  now,  should  this  diameter 
exceed  this  measurement  but  a  quarter  of  an  inch,  or  even  less, 
it  would  create  a  difficulty  that  would  menaces  the  life  of  the  child. 
1  well  remember  once  to  have  sorely  repented  the  trial,  where  I 
judged  the  small  diameter  of  the  superior  strait,  would  certainly 
have  been  equal  to  three  inches  and  a  half. 

1539.  It  will,  therefore,  follow,  that  turning  in  a  confined  pel- 
vis is,  and  must  be,  of  doubtful  safety,  as  regards  the  child.  As  one 
calculated  to  relieve  the  mother,  or  simply  to  terminate  a  labour, 
without  taking  into  view  its  effects  on  the  child,  it  might  in  ma- 
ny instances  be  successful;  or,  if  the  practitioner  has  been  deba- 
ting within  himself,  the  comparitive  merits  of  the  crotchet  or 
turning,  the  latter  will  unquestionably  merit  the  preference;  since 
it  gives  a  chance,  though  a  forlorn  one,  to  the  child.  But  let  it 
be  observed,  the  consideration  should  have  turned  upon  the  em- 
ployment of  the  forceps,  and  not  upon  that  of  the  crotchet,  for 
this  should  always  be  considered  as  a  dernier  resource. 

1540.  We  have  stated,  as  one  of  the  essentials  to  easy  and  safe 
turning,  that  a  proper  relation  of  diameters  should  exist  between 
the  pelvis  of  the  mother  and  the  head  of  the  child.  In  laying 
down  this  axiom,  we  would  wish  to  be  clearly  understood  to 
mean,  the  absolute  proportions,  and  not  the  relative.  Or,  in  other 
words,  the  respective  diameters  of  the  pelvis,  shall  be  of  such  ca- 
pacity as  will  permit  the  head  to  pass  without  any  material  ob- 
struction when  its  corresponding  diameters  shall  be  presented  to 
them.  If  this  be  not  the  case,  the  force  which  must  necessarily 
be  employed  to  overcome  the  resistance  created  from  the  want 
of  this  proper  relation  of  diameters  will  be  such,  as  but  too 
surely  to  destroy  the  child,  and  create  at  the  same  time,  difficul- 
ties, which  perhaps  can  only  be  overcome,  by  the  use  of  cutting 
instruments. 

1541.  Again,  we  have  said,  that,  besides  the  proper  corres- 
pondence of  diameters  as  just  stated,  it  is  almost  a  sine  qua  non, 
that  the  waters  should  not  have  been  too  long  drained  off",  to  ren- 
der even  this  favourable  disposition  available.  For  it  is  a  truth, 
which  almost  every  accoucheur  must  acknowledge  who  has  at- 


OF  THE  FORCEPS  IN  A  DEFORMED  PELVIS.  551 

tempted  to  turn  in  a  strongly  contracting  uterus,  that  the  want 
of  success  by  this  operation,  even  in  a  well-formed  pelvis,  is  too 
often  owing  to  its  being  undertaken  when  the  uterus  is  very 
firmly  embracing  the  child.  If  then,  we  have  to  contend  against 
the  two  difficulties  just  enumerated,  it  is  more,  perhaps,  than  ten 
to  one,  that  we  do  not  succeed,  in  saving  the  child. 

1542.  We  have  also  enumerated  as  another  essential  to  the 
safety  of  the  child,  that  its  breast,  as  well  as  the  umbilical  cord, 
shall  not  suffer  compression.  But  what  skill  or  foresio-ht,  can 
guard  against  such  a  contingency  ;  nay,  almost  against  such  a 
certainty  ?  And  if  this  be  beyond  our  control,  as  it  too  surely 
is,  we  need  not  wonder,  at  so  many  instances  of  failure,  in  this 
operation. 

1543.  We  must  again  repeat,  that  the  head  must  not  be  too 
long  detained  in  the  pelvis  if  success  is  to  attend  our  exertions. 
But  who  can  declare  that  this  shall  not  take  place  ?  since  the  ex- 
ercise of  the  most  consummate  skill  cannot  insure  it;  and  who 
can  guard  against  the  ill-devised  manipulations  of  ignorance  ? 

1544.  Finally,  we  have  declared,  that  the  neck  of  the  child 
must  not  suffer  too  much  extension.  But  who  can  insure  the  life 
of  the  child  against  such  a  necessity,  even  in  the  hands  of  the 
skilful  ? 

1545.  From  what  we  have  said,  the  conclusion  will  be  easily- 
collected  ;  that  even  under  the  more  favourable  circumstances, 
turning  is  to  the  child  a  hazardous  operation  ;  but  that  under  per- 
verse ones,  it  is  but  too  often  fatal  to  it ;  and,  that  it  must 
ever  be  looked  upon  as  a  doubtful  alternative,  rather  than  as  a 
probably  safe  resource. 

Sect.  II. — b.   Of  the  Forceps  in  a  Deformed  Pelvis. 

1546.  In  my  general  view  (761)  of  the  forceps,  I  endeavoured 
to  prove  that  their  powers  were  pretty  extensive,  yet  sufficiently 
limited.  That  their  mode  of  action  (784)  was  that  of  a  double 
lever,  with  no  mean  compressing  power — that  this  power,  how- 
ever, could  not  be  successfully  employed  (781)  beyond  a  certain 
degree,  with  safety  to  the  child.  That,  if  more  were  exerted,  it 
would  be  at  the  expense  of  the  bones  of  the  cranium,  and  the 
brain  of  the  child ;  therefore,  there  was  a  limit  to  their  usefulness. 
In  a  pelvis  where  the  opening  of  the  superior  strait  in  its  small 
diameter  will  give  three  inches,  these   instruments  have  been 


552  OP  THE  FORCEPS  IN  A  DEFORMED  PELVIS. 

successfully  employed;  of  which  Baudelocque*  gives  us  an  ex- 
ample which  not  only  proves  the  useful  powers  of  these  instru- 
ments, but  shows  the  little  certainty  with  which  the  death  of  the 
child  is  marked,  even  by  the  combination  of  many  of  the  most 
formidable  signs.  This  case  is  full  of  instruction,  and  should  be 
carefully  read. 

1547.  But  when  the  small  diameter  of  the  superior  strait  has 
less  than  three  inches,  these  instruments  cannot  be  employed  at 
the  full  period  of  utero-gestation  with  any  chance  of  success.  To 
be  useful  even  then,  requires  that  the  head  of  the  child  shall  be  of 
moderate  size,  and  yielding;  well  situated,  and  that  a  skilful  hand 
should  apply  them.t  As,  however,  they  offer  a  better  chance,  if 
properl}^  conducted  upon  the  head  than  turning,  they  should  be 
employed  always  in  preference  to  this  operation,  when  even  a 
force  not  to  be  called  great,  would  be  required  to  make  the  head 
pass  the  superior  strait;  for  the  child  will  suffer  less  from  a  com- 
pression of  the  head,  than  from  the  severe  extension  of  its  neck; 
which  it  must  necessarily  undergo,  when  detained  in  a  pelvis,  in 
which  the  opening  is  less  than  four  inches. 

1548.  It  must,  however,  not  be  concealed,  that  these  instru- 
ments are  not  safe,  under  the  circumstances  we  are  now  consi- 
dering, but  in  the  hands  of  a  few;  and  are  only  rendered  so  to 
them,  by  their  superior  professional  attainments,  and  the  long 
habit  of  using  them.  To  the  inexperienced  practitioner,  they 
should  be  entirely  forbidden;  not  only  because  they  may  destroy 
the  child,  but  also  because  the  mother  may  be  severely,  or  irre- 
parably injured  by  their  use.  Should,  however,  the  defect  of 
size  be  in  the  lower  strait,  and  that  not  excessive,  the  forceps 
will  every  now  and  then  answer  a  valuable  end,  as  the  following 
case  will  prove: 

Mrs. had  been  in  labour  nearly  six-and-thirty  hours  with 

a  first  child;  the  early  part  of  her  labour  had  been  slow,  but  re- 
gular in  its  progress.  The  midwife  to  whose  aid  I  was  called,  in- 
formed me,  that  the  waters  had  been  discharged  after  the  uterus 

»  System,  par.  1898. 

■}•  "  But,  inasmuch  as  we  have  not  discovered  th^  means  of  applying  sucli 
pressure  to  and  for  the  benefit  of  the  child,  without,  in  the  meantime,  compro- 
mising' the  more  important  interests  of  the  mother,  it  should  be  held  as  the 
bounden  duty  of  our  art,  in  the  treatment  of  such  cases,  (cases  of  narrow  pelves) 
to  refrain  from  all  inordinately  forcible  attempts  to  deliver  with  the  forceps." 
— Dr.  Dauis's  Elem.  Opcr.  Mid.  p.  140. 


OP  THE   FORCEPS  IN  A  DEFORMED  PELVIS.  553 

Was  well  dilated;  the  pains  had  all  along  been  good;  that  the 
child  was  very  loio,  and  seemed  every  moment  ready  to  come, 
yet  did  not  advance;  for  so  soon  as  the  pain  ceased,  it  flew  back  to 
its  old  place,  and  had  done  so  for  many  hours. 

The  woman  was  in  good  health  and  spirits,  notwithstanding  the 
length  and  severity  of  her  sufferings;  she  was  free  from  fever; 
had  had  her  bowels  opened,  and  passed  urine  but  a  short  time  be- 
fore my  seeing  her — she  was  short  of  stature;  waddled  when  she 
walked;  and  was  very  bow-legged.  Upon  examining  her,  I  found 
that  the  lower  strait  was  defective  in  its  small  diameter;  the  tu- 
bers of  tlie  ischia  approached  too  much,  and  thus  did  injury  to 
the  arch  of  the  pubes  also.  I  waited  for  a  pain  to  determine  its 
influence — the  head  was  well  situated,  but  could  not  descend  low 
enough  to  enable  the  vertex  to  pass  under  the  arch  of  the  pubes; 
it  was,  therefore,  found  rather  mounted  behind  it.  The  head 
did  not  appear  large,  and  its  bones  were  supple. 

When  a  pain  came  on,  the  parietal  bones  rode  over  each  other, 
and  the  scalp  was  pushed  considerably  in  advance.  I  waited  to 
try  the  influence  of  two  or  three  more  pains;  but  the  head  only 
advanced  during  their  action;  for  so  soon  as  this  ceased,  it  raised 
upwards,  as  it  had  done  for  a  long  time,  as  stated  by  the  midwife. 
The  cause  of  the  delay  was  obvious — the  parietal  protuberances 
could  not  be  forced  by  the  uterus,  below  the  tubers  of  the  ischia, 
that  the  head  might  pass  througli  the  external  parts.  I  was  of 
opinion  that  nothing  could  relieve  the  head  from  its  perilous  si- 
tuation but  the  forceps;  accordingly,!  made  it  known  to  the  friends 
of  the  patient,  and  subsequently  to  the  patient  herself— she  cheer- 
fully acquiesced  in  the  decision;  the)^  were  applied,  and  by  mere- 
ly maintaining  the  ground  gained  by  each  uterine  effort,  without 
exerting  much  tractive  force,  I  succeeded  in  half  an  hour  to  de- 
liver the  poor  woman  of  a  living  female  child.  The  head  was 
elongated  to  an  unusual  degree;  but  it  recovered  its  natural  shape 
in  a  few  days.* 

1549.  It  is  not  intended  by  what  has  been  said,  to  discourage 
the  obstetric  practitioner  in  the  use  of  the  forceps,  in  cases  in 
which  their  application  might  be  difficult;  on  the  contrary  we 
would  earnestly  recommend  to  him  the  careful  study  of  their 
mode  of  action,  and  the  various  manners  in  which  they  are  to  be 

*  I  was  ever  after  obliged  to  deliver  this  patient  with  the  forceps:  tiiis  hap- 
pened four  times;  and  without  the  smallest  accident  to  either  mother  or  cliild. 
70 


554  OF  THK  FORCEPS  IN  A  DEFORMED  PELVIS. 

applied.  The  usefulness  and  agency  of  these  instruments  in  pre- 
serving the  life  of  the  child,  as  well  as  that  of  the  mother,  is  no 
longer  problematical;  for  they  have  been  confirmed  by  the 
united  testimony  of  the  European  and  American  practitioners  of 
midwifery,  for  the  last  fifty  years. 

1550.  Important,  however,  as  the  forceps  are  known  to  be  by 
medical  men,  neither  they,  nor  the  skill  which  directs  them,  are 
sufficiently  appreciated  by  the  public  at  large;  indeed,  the  prac- 
tice of  obstetrics  is  very  far  from  being  justly  valued;  and  this 
must  for  a  long  time  remain  so  we  fear,  as  the  public  cannot  easily 
be  set  right  upon  its  utility.  This  involuntary  injustice  to  this 
branch  of  medical  science,  arises  mainly  from  the  following  causes. 
First,  from  the  process  of  parturition  being  constantly  viewed  as 
an  act,  in  which  the  practitioner  has  no  other  concern,  than  to 
silently  watch  the  operations  of  nature.  This  we  acknowledge 
is  strictly  true  in  a  very  great  majority  of  cases;  but  in  admitting 
this,  we  are  not  to  pass  over  without  observation,  the  exceptions, 
or  those  instances  which  require  both  prompt  and  judicious  inter- 
ference. But  these  exceptions  are  entirely  lost  sight  of;  and  they 
are  lost  sight  of  in  many  instances,  because  they  cannot  with  pro- 
priety be  made  to  meet  the  public  eye,  and  this  for  reasons  that  will 
readily  present  themselves  to  a  thinking  mind,  as  well  as  the  aver- 
sion every  ingenuous  mind  has  to  the  appearance  of  vain  boasting. 
Yet  the  skilful  practitioner  has  it  often  in  his  power  to  felicitate 
himself,  that  he  has  abridged  severe  suffering,  or  preserved  hu- 
man life;  but  for  which,  he  neither  expects,  nor  can  he  receive, 
any  evidence  of  public  approbation.  This  does  not,  however, 
arise  from  any  reluctance  on  the  part  of  the  world  to  do  him 
justice,  but  because  the  nature  of  his  exertions,  and  the  indispen- 
sable application  of  his  skill,  must  for  the  most  part  remain  un- 
known, to  every  body  but  himself. 

1551.  Second.  The  difficulties  with  which  the  accoucheur  has 
to  contend,  are  almost  unknown  out  of  the  profession;  on  this 
account,  the  most  important  operation  which  can  possibly  be  per- 
formed, namely,  the  preservation  of  life  by  the  use  of  the  forceps, 
is  put  upon  a  par,  nay,  it  is  often  placed  below,  some  of  the  most 
trifling  operations  of  surgery;  for  the  public  are  not  aware,  that 
the  most  difficult  operation  on  the  living  subject,  is  the  scientific 
application  of  the  forceps,  when  the  head  of  the  child  has  not  de- 
scended so  low  as  to  occupy  the  vagina. 

1552.  How  mucli  greater  eclat  do  most  of  the  operations  of  sur- 


CEPHALOTOMV.  555 

gery  obtain,  than  a  delivery  by  the  forceps!  yet  we  do  not  fear, 
nor  do  we  hazard  a  contradiction  when  we  say,  there  is  no  ope- 
ration in  all  surgery,  that  is  not  of  more  easy  attainment,  than 
the  rational  and  just  application  of  the  forceps. 

1553.  Third.  The  comparative  estimate  of  the  mother's  and 
the  child's  lives,  contributes  very  much  to  lessen  the  value  of  ma- 
nual interference  in  cases  of  difficult  labour.  For  when  anything 
untoward  arises,  the  life  of  the- mother  alone  is  taken  into  the 
calculation;  the  child  may  oe  immolated  without  a  sigh,  provided 
it  be  declared  that  either  it,  or  the  mother  must  be  sacrificed. 
And  if  it  be  preserved,  it  is  looked  upon  rather  as  a  piece  of  good 
fortune,  than  as  an  evidence  of  any  superior  skill  on  the  part  of 
the  practitioner. 

1554.  But  let  us  not  bs  supposed  to  charge  the  public  with  vo- 
luntary injustice  on  this  subject;  this  is  far  from  our  meaning; 
we  only  wish  to  insist,  that  the  difficulties  oftentimes  to  be  over- 
come by  the  accoucheur,  in  order  to  save  life,  is  altogether  con- 
cealed from  public  view;  and  of  the  value  of  which  of  course 
they  cannot  accurately  judge.  Yet  we  feel  it  is  proper  that  some 
delicate  and  proper  effiart  should  be  made  to  elevate  the  character 
of  the  well-instructed  accoucheur  above  the  ignorant  and  pre- 
tending practitioner;  and  to  have  a  just  value  set  upon  the  most 
difficult  operation,  in  the  range  of  medical  science. 


Sect.  III. — c.  Cephalotomy. 

1555.  This  operation  destroys  the  child,  with  the  intention,  it 
is  said,  to  save  the  life  of  the  mother,  by  preventing  her  from 
dying  undelivered,  or  subjecting  her  to  the  Caesarean  operation. 
Dr.  Osborn  has  treated  this  subject  under  two  distinct  heads; 
in  conducting  which  he  inquires,  1st.  "Into  the  degree  of  de- 
formity, requiring  the  crotchet,  the  Caesarean  operation,  or  the 
division  of  the  symphysis  pubis;  their  comparative  merit  ex- 
amined;" 2d.  Pie  then  makes  a  "comparative  estimate  of  the 
mother's  life,  and  the  life  of  the  child  in  utero." 

1556.  His  first  inquiry  results  in  his  giving  the  preference  to  the 
crotchet;  and  from  the  following  views.  "  He  says,  whenever  the 
pelvis  is  so  distorted  in  its  form,  and  so  contracted  in  its  capacity, 
as  not  to  permit  the  head  of  the  child  to  pass  unopened,  it  consti- 
tutes tiiat  degree  of  laborious  parturition,"  for  which  the  conipa- 


550  CEPHALOTOMY. 

rison  of  the  merits  of  the  crotchet,  with  that  of  the  Csesarean  ope- 
ration, &c.  was  instituted.    Essays,  p.  25.* 

1557.  That,  "whenever  a  woman  falls  in  labour,  the  small 
diameter  of  whose  pelvis  measures  only  two  inches  and  three- 
quarters,  one  of  the  following  circumstances  must  take  place." 

155S.  «' First,  the  child's  head  must  be  opened,  and  the  con- 
tents discharged,  that  the  bones  may  be  permitted  to  collapse, 
and  the  volume  being  thus  diminished,  it  may  afterwards  be  ex- 
tracted with  the  crotchet;"  or, 

1559.  "Secondly,  for  the  certain  preservation  of  the  child's 
life,  the  mother  must  be  doomed  to  inevitable  destruction,  by 
the  Csesarean  operation:"  or, 

1560.  "Thirdly,  as  a  mean  between  the  two  extremes,  the 
mother  must  submit  to  the  section  or  division  of  the  symphysis 
pubis;  an  operation  of  less  danger  to  the  parent  than  the  Caesa- 
rean  section,  but  at  the  same  time  certainly  less  safe  for  the 
child;"  or, 

1561.  "Lastly,  if  none  of  these  means  will  be  permitted,  the 

*  It  would  seem  that  theorj',  or  conjecture,  has  had  much  to  do  in  fixing'  the 
nature  and  value  of  the  child's  hfe  while  in  utero;  and  that  the  low  estimate  at- 
tached to  them,  has  arisen  more  from  terms,  than  a  difference  of  qualities.  Thus 
Alphonso  Le  Roy  tells  us,  that  "the  birth  of  animals  is  a  quick  passag-e  from 
one  mode  of  existence  to  that  of  another."  And,  "  that  the  child,  while  in  ute- 
ro, hves  after  the  same  manner  as  a  veg-etable."  Velpeau  has  adopted  these 
sentiments,  with  no  additional  value  to  the  profession.     Med.  Matern.  p.  4. 

For  we  would  ask,  does  this  comparison  prove  other,  than  that  the  child  has 
life?  Is  it  not  a  dispute  about  terms,  to  call  the  life  of  the  foetus  while  in  utero 
vegetable  life;  and  tlvat  which  maintains  its  existence  after  birth,  animal  life? 
Has  any  one  demonstrated  that  there  is  any  difference  in  the  quality  of  that 
principle,  which  we  term  hfe  in  these  two  conditions  of  the  animal?  Does  not 
tlie  difference  consist  simply  in  the  manner  in  which  this  principle  is  maintain- 
ed ?  or  in  other  words,  are  not  precisely  the  same  principles  essential  to  the 
child  both  before  and  after  delivery  ?  Certainly  they  are.  While  it  is  in  utero, 
does  not  the  foetus  require  circulation,  oxygenation,  and  nutrition,  as  much, 
quo  ad  hoc,  as  after  it  is  born?  That  these  essentials  to  its  existence  are  apphed 
differently,  and  maintained  differently,  we  agree;  but  the  nature,  and  import- 
ance of  the  means,  and  agents  are  precisely  the  same.  For  the  child  would  un- 
questionably die  in  utero,  were  either  circulation,  oxygenation,  or  nutrition 
withheld  beyond  a  limited  time;  and  death  would  follow,  were  either  of  these 
grand  agents  abstracted  but  for  a  short  period  after  birth. 

In  a  moral  point  of  view,  the  turpitude  of  destroying  the  life  of  the  foetus  by 
design,  call  it  vegetable,  or  animal,  as  you  please,  will  be  the  same;  nor  must 
we  permit  ourselves  to  undervalue  it,  or  be  seduced  to  destroy  it  wantonly,  by 
employing  terms  which  have  no  definite  meaning;  or  if  they  have  a  definite 
meaning,  the  destruction  of  the  principle  called  hfe,  must  in  a  moral  light,  be 
viewed  as  a  crime. 


CEPHALOTOMV.  557 

wretched  mother,  abandoned  by  art  to  the  excruciating  and  un- 
availing anguish  of  labour,  will  probably  expire  undelivered." 

1562.  From  this  it  would  appear,  that  every  woman  who  has 
less  than  three  inches  in  the  small  diameter  of  the  superior  strait, 
must  die,  or  be  delivered  by  the  crotchet,  by  the  Csesarean  ope- 
ration, or  the  section  of  the  pubes,  if  at  the  full  period  of  utero- 
gestation.  In  this  all  writers  agree.  But  Dr.  Osborn  is  of  opinion 
that  nothing  but  the  crotchet  should  ever  be  employed  under  such 
circumstances,  unless  the  opening  at  the  superior  strait  has  less 
than  one  inch  and  a  half;  for  when  there  is  this  opening  in  the 
antero-posterior  diameter  of  the  superior  strait,  the  child  can  be 
extracted  by  the  crotchet,  p.  64,  and  whenever  a  child  can  be  ex- 
tracted by  the  crotchet,  neither  of  the  other  operations  should  be 
thought  of. 

15G3.  He  is  led  to  this  conclusion,  first,  from  his  estimate  of  the 
value  of  the  child's  life  while  in  utero,  when  compared  with  that 
of  the  mother.  He  declares  the  former  to  be  "  incomparably 
small,"  nay, ''  diminished  almost  to  nothing,  and  affords  the  most 
irrefragable  argument  in  favour  of  the  delivery  by  the  crotchet  in 
preference  to  either  of  the  other  methods,"  p.  24.  And  secondly, 
from  his  having  delivered  a  woman  safely  by  the  crotchet,  whose 
pelvis  was  said  not  to  exceed  one  inch  and  three  quarters,  at  the 
upper  strait. 

1564.  Dr.  Osborn  commences  his  inquiry  by  stating,  "  a  being 
in  the  uterine  state  of  existence,  sustains  no  immediate  loss  by 
the  deprivation  of  the  living  principle,  and  can  scarcely  be  said 
to  incur  any  other  positive  injury.  Before  the  operation,  the  child 
in  utero  cannot  suffer  mental  anxiety,  or  apprehension  from  the 
threatened  violence;  nor  does  it  feel,  I  am  persuaded,  the  smallest 
bodily  pain,  in  the  actual  commission  even  of  such  violence."  The 
question  is  not  fairly  stated  here — it  is  not  whether  the  child 
suffer  from  this  violence  or  not;  the  question  is,  whether  it  shall 
have  a  chance  to  live,  or  be  destroyed  ?  the  feelings  of  the  child 
must  not  be  taken  into  consideration,  in  weighing  the  question, 
which  life,  that  of  the  mother,  or  that  of  the  child,  must  be  sacri- 
ficed. For  if  we  deal  honestly  upon  this  subject,  and  conclude, 
that  the  life  of  either  the  mother  or  child  must  be  forfeited,  we 
are  forced  to  the  admission,  that  the  child  should  be  immolated, 
to  preserve  the  mother.  It  then  becomes  fairly  a  matter  of  com- 
parison, which  is  tlie  most  valuable  to  society  in  all  its  relations. 
And  I  would  yield  the  point  without  hesitation  in  favour  of  the 


558  CEPHALOTOMY. 

mother's  preservation;  and  I  would  do  so*  were  the  child  a  thou- 
sand times  more  sensible  tlian  it  is.  For  did  we  withhold  an  ope- 
ration from  a  persuasion  that  the  child  in  utero  is  endowed  with 
great  sensibility,  and  that  like  ''the  poor  beetle  that  we  tread 
upon,  in  corporeal  suffering;  finds  a  pang  as  great  as  when  a  giant 
dies,"  I  say, did  we  withhold  an  operation  essential  to  the  mother's 
welfare,  from  these  considerations  we  should  be  exalting  the  mere 
sensibility  of  the  child  above  the  usefulness  and  importance  of  the 
mother,  to  the  husband,  parents,  friends,  and  to  society.  I  must 
therefore  insist,  that  the  sensibility  of  the  child,  be  its  degree  what 
it  may,  must  not  be  taken  into  the  account,  when  this  question  is 
agitated. 

1565.  But  let  us  believe  the  child  to  be  as  void  of  sensibility 
as  a  cabbage,  or  any  other  vegetable,  while  in  utero;  what  does 
this  prove  as  regards  the  proper  question?  certainly  nothing — 
for  necessity,  and  that  necessity  absolute,  can  alone  justify  the 
operation.  For,  were  we  to  permit  our  sympathies  to  get  the 
better  of  our  duty;  and  suffer  the  mother  to  die  from  the  exercise 
of  feeling  toward  the  child,  we  destroy  her  by  such  a  proof  of  our 
sensibility;  while  on  the  other  hand,  if  we  wantonly  or  heedlessly 
kill  the  child,  because  we  have  persuaded  ourselves  it  possesses 
nothing  more  than  vegetable  life,  or  life  without  sensation,  we 
murder  it,  in  conforming  to  an  hypothesis.  I  therefore  repeat, 
that  the  properties  of  the  child,  be  they  what  they  may,  must 
never  enter  into  the  calculation,  when  it  is  inevitably  fixed  that 
either  it  or  the  mother  must  be  the  victim. 

1566.  The  Doctor  next  declares,  "  as  children  before  birth  are 
incapable  oi  mental  apprehension,  so  it  is  as  undoubtedly  true, 
that  they  are  not  yet  arrived  at,  or  in  possession  of,  bodily  sen- 
sation, and  therefore  cannot  suffer  pain  or  become  objects  of 
cruelty."  I  would  inquire,  how  has  the  Doctor  ascertained  that 
"  children  before  birth  are  incapable  of  mental  apprehension?" 
for  on  this  his  remarkable  conclusion  is  founded.  Has  he  any 
proof  whatever  that  this  is  really  the  case  ? 

1567.  But  before  I  proceed  farther,  let  me  show  what  Dr. 
Osborn  means  by  "  mental  apprehension." — "  Before  the  opera- 
tion, (of  cephalotomy,)  the  child  in  utero  cannot  sufier  mental 
anxiety,  or  apprehension  from  threatened  violence;  nor  does  it 
feel,'  I  am  persuaded,  the  least  bodily  pain  in  the  actual  commis- 
sion even  of  such  violence,"  p.  36.  Again,  "it  is  certainly  from 
that  apprehension,  combined  with  other  circumstances  of  misery. 


CEPHALOTOMY.  559 

which  usually  precede  and  accompany  the  act  of  dying,  that  deatli 
can  in  itself  be  considered  as  the  greatest  of  human  evils — and 
from  every  one  of  those,  the  child  in  utero  is  exempt."  p.  37. 

1568.  From  this  it  is  evident.  Dr.  Osborn  supposes  that  bo- 
dily sensation  is  dependent  upon  "mental  apprehension,"  or  in 
other  words,  that  there  can  be  no  "corporeal  suffering,"  if  there 
were  no  "mental  apprehension."  Is  this  agreeable  to  common, 
and  daily  observation?  Has  not  the  devoted  ox,  power  to  per- 
ceive the  "smallest  bodily  pain,"  because  it  cannot,  or  does  not 
anticipate  its  fate  from  the  butcher's  axe  on  the  morrow  ?  Were 
we  to  adopt  this  hypothesis,  it  would  make  "mental  apprehen- 
sion" tlie  cause  of  corporeal  sensation,  which  would  most  effec- 
tually confound  all  our  philosophy. 

1569.  If  I  should  be  charged  with  having  wrested  Dr.  O.'s 
meaning,  though  I  have  fairly  quoted  his  words;  if  it  should  be 
insisted  that,  "mental  apprehension,"  meant  perception,  still  the 
doctor  is  chargeable  with  having  employed  a  gratuitous  datum — 
for  he  has  not  proved,  that  the  brain  of  the  foetus,  especially  at 
full  time,  (the  period  at  which  the  operation  he  advocates  is  to  be 
performed,)  is  incapable  of  perception;  and  until  this  be  done,  it 
is  in  vain  to  contend,  that  the  child  in  utero  cannot  feel  "the 
smallest  bodily  pain."  On  the  contrary,  does  not  the  child  ac- 
knowledge this  in  many  instances?  Is  it  not  frequently  provoked 
by  external  causes  to  move  its  little  limbs?  Nay,  does  it  not  do 
this  very  frequently  without,  to  us,  an  obvious  cause?  May  these 
stirrings  not  be  considered  as  the  exorcise  of  volition?  Has  it 
not  a  brain,  and  nerves  emanating  from  it?  Are  these  nerves 
mere  cords  without  sensibility?  Is  the  brain  a  mere  glandular 
mass  without  function?  I  can  readily  believe  their  condition  to 
be  imperfect,  but  I  cannot  admit  them  to  be  without  power  or 
property. 

1570.  Does  not  the  heart  carry  on  the  circulation  as  certainly, 
and  as  perfectly,  quo  ad  hoc,  in  the  foetus  as  in  the  born  child? 
Could  this  organ  perform  its  functions  without  a  certain  condition 
of  the  nervous  system?  If  this  be  so,  can  the  nerves  be  mere 
cords,  without  sensibility?  If  the  nerves  belonging  to  the  heart 
be  sensible,  may  not  all  others  be  so? 

1571.  In  my  opinion,  then.  Dr.  0.  has  not  made  good  his  po- 
sition; a  position  on  which  he  appears  to  place  much  reliance  for 
the  supportof  his  thesis,  though  in  mine  it  has  nothing  to  do  with 
the  question,  as  1  have  just  observed,  (1564,  1565)  fori  must  re- 


560  CEPHALOTOMY. 

peat,  that  necessity,  and  strong  necessity,  alone  can  justify  the 
operation  under  consideration — the  preservation  of  the  mother's 
life  is  the  only  motive  to  action,  and  the  only  ohject  in  view — if 
the  child  must  be  the  sacrifice  for  the  mother's  safety,  that  sacri- 
fice is  imperious,  be  the  condition  of  the  child  what  it  may. 

1572.  Dr.  Osborn  next  informs  us,  "  that  they  (children  in 
utero)  cannot  suffer  from  mental  apprehension,  is  notorious  to  ge- 
neral observation.  Even  years  elapse  after  birth,  before  the  mind 
is  susceptible  of  fear,  or  apprehensive  of  danger."  Admitted  : 
but  what  does  this  truism  prove,  as  regards  the  subject  in  ques- 
tion? Nothing;  for  I  still  must  insist,  that  necessity  alone  is  to 
govern  us;  and  if  governed  by  that,  the  only  question  to  be  de- 
bated is,  whether  the  child  is  to  be  absolutely  sacrificed,  for  the 
jirohable  safety  of  the  mother?  I  say  probable  safety — for  such 
only  it  is,  as  I  shall  attempt  to  prove  presently. 

1573.  If  we  are  under  the  necessity  of  opening  the  child's  head 
our  social  feelings  would  derive  some  solace,  could  we  be  sure  it 
did  not  suffer,  or  were  we  even  uncertain  of  its  suffering  from 
the  operation;  but  every  thing  opposes  our  drawing  comfort 
from  this  source;  for  however  our  understanding  may  be  con- 
founded by  specious  argument,  or  wily  sophism,  our  feelings  will 
constantly  bear  witness  against  the  truth  of  the  propositions,  and 
the  legitimacy  of  the  conclusions.  And  I  believe  that  God  intend- 
ed it  should  be  so.  What  evils  would  flow  from  this  source,  did 
we  but  convince  ourselves,  that  foetal  life  was  void  of  sensibility, 
sensation,  or  of  value. 

1574.  The  crotchet  has  been  but  too  often  wantonly  employed, 
even  where  the  practitioner  had  not  adopted  Dr.  Osborn's  opinion 
on  the  subject  of  foetal  sensibility;  how  much  more  frequently 
then,  will  it  be  employed,  when  the  wholesome  restraint  of  the 
contrary  opinion  is  removed?  I  am  persuaded  that  the  exercise 
of  true  feeling  toward  the  unborn  child,  has  more  than  once 
saved  it  from  a  severe  and  painful  fate;  but  it  must  also  be  de- 
clared as  my  opinion,  that  it  has  too  often  fallen  a  victim  to  a 
false  estimate  of  the  mother's  danger — for  I  have  known  it  used 
where  there  was  the  most  healthy  construction  of  the  pelvis,  and 
where  a  little  address  in  the  use  of  the  forceps,  or  even  a  little 
more  patience,  would  have  preserved  the  child  from  a  premature 
death.* 

*  I  am  happy  to  find  my  opinion  on  this  subject  strengtlicncd  by  a  similar  re- 


CKPHALOTOMV.  5GI 

1575.  Dr.  Osborn  further  informs  us,  that  "diseases  which  at 
any  period  attack  the  human  body  possessing  sensation,  with 
sufficient  force  to  destroy  life,  are  in  general  attended  with  such  a 
degree  of  pain,  as  to  excite  extraordinary  motion,  and  some  strug- 
gle; at  least  in  articulo  mortis.  It  is  highly  improbable  that 
this  should  take  place  in  the  uterus,  and  the  mother  be  insensi- 
ble of  their  effect,"  p.  40.  This  statement  at  once  brings  Dr. 
Osborn's  arguments  to  issue.  He  declares  the  struggle  of  an  in- 
fant in  utero  would  be  an  evidence  of  pain,  and  of  course  of  its 
possessing  ''sensation;"  and,  that  if  this  struggle  did  take  place 
even  in  articulo  mortis,  it  is  highly  probable  that  the  mother 
would  be  sensible  of  it — now,  what  is  the  fact  upon  this  sub- 
ject? Why,  that  I  have  been  repeatedly  informed  by  mothers, 
that  they  were  apprehensive  their  children  were  dead,  because 
after  a  severe  struggle  or  kind  of  fluttering,  which  has  been  de- 
scribed of  longer  or  shorter  duration,  they  felt  them  no  more — 
and  every  accoucheur  can  bear  witness  to  such  statements  from 
them. 

1576.  Dr.  Osborn  farther  urges,  that,  ^' when  we  are  compelled 
by  dreadful  necessity,  to  open  the  child's  head  while  we  know  it 
is  living  in  utero,  that  operation  requires  such  extreme  o^n^  jjainful 
violence,  that,  were  the  child  endowed  with  the  slightest  sensa- 
tion, he  must  of  necessity  feel  it;  and  his  feelings  must  necessarily 
be  accompanied  with  such  struggles  and  exertions,  as  would  be 
emphatically  expressive  of  pain,  and  must  be  readily  perceived 
b}^  the  mother  in  a  part  so  sensible  and  irritable  as  the  uterus." 
p.  41. 

1577.  This  is  sheer  sophistry — it  is  making  a  negative  condition 
prove  a  positive  position;  or,  in  other  words,  it  is  making  the 
absence  of  struggling  prove  the  want  of  sensation;  when  the  si- 
tuation of  the  child  in  utero  is  such,  very  often  when  it  is  neces- 
sary to  perform  this  operation,  as  to  render  such  evidence  of  its 
sufferings  impossible.  For  this  operation  is  recommended  to 
be  performed  after  the  waters  have  been  expended,  and  the 
uterus  is  firmly  contracting  round  the  body  of  the  child.  Now,  it 
is  well  known  to  every  accoucheur  of  any  experience,  that  the 
uterus  will  in  many  instances  so  strictly  gird  the  child,  as  to 

mark  by  Dr.  James,  wiiose  opportunities  afford  Iiim  ample  room  to  witness  the 
abuse  of  tliis  instrimient  in  the  hands  of  ig'norant  practitiopers:  in  a  note  to 
Burns's  Midwifeiy,  p.  c,5,  note  k,  he  says,  he  fears  that  "enibryulciais  fi-equent- 
ly  resorted  to  veiy  unnecessarily  at  least,  to  make  use  of  the  mildest  terms." 
71 


562  CEPHALOTOMY. 

preclude  the  possibility  of  "  exertion,"  be  its  feelings  what  they 
may. 

157S.  Besides,  in  a  case  which  T  witnessed  of  the  operation  of 
cephalotomy,  the  woman  declared  to  me  without  inquiry,  that 
the  most  painful  part  of  it  was  the  struggles  of  the  child.  Now 
in  this  case  the  waters  had  been  but  recently  discharged,  and  the 
uterus  contracted  but  once  in  about  twenty  minutes.  I  mean  not 
to  lay  undue  stress  upon  this  case;  for  it  is  not  essential  to  my 
argument.  I  well  know  the  imagination  does  much  upon  such 
occasions;  and  that  a  convulsive  action  of  the  uterus  may  have 
been  mistaken  for  the  motions  of  the  child;  though  it  was  pre- 
cisely such  a  case  as  would  lead  to  the  belief,  that  the  poor 
woman  was  correct;  for  the  child  was  certainly  alive  when  the 
operation  commenced;  the  waters  had  been  expended  but  a 
short  time;  and  the  woman's  observation  was  spontaneous,  and 
unprovoked. 

1579.  Dr,  Osborn,  however,  tell  us  on  the  contrary,  that"  upon 
accurate  and  repeated  inquiry  in  several  such  cases,  he  could  not 
learn  that  the  mother  was  sensible  of  any  such  alteration  in  the 
motion  of  the  child,  even  at  the  commencement  of  the  operation, 
when  the  violence  offered  to  it  first  takes  place,  and  must  be 
most  painful."  This  statement  of  Dr.  O.'s  amounts  but  to  this 
negative;  that  in  the  cases  in  which  he  made  <' repeated  in- 
quiry," no  struggles  were  perceived;  but  this  is  very  far  from 
proving,  that  none  upon  any  occasion  could  take  place.  For 
this  might  well  happen  in  "  several  cases,"  yet  not  be  true  in 
all;  and  if  there  have  been  one  case  in  which  the  child  was 
known  to  struggle  in  consequence  of  the  operation,  it  is  every 
way  sufficient  to  destroy  the  arguments  of  Dr.  0.;  since  he  makes 
struggling  a  proof  of  sensibility — and  I  most  sincerely  believe 
many  such  cases  have  occurred.  There  are  two  especial  rea- 
sons why  this  maiy  not  commonly  happen:  1st.  As  stated,  (1577;) 
and  2d.  The-  child  is  sometimes  dead  before  the  operation  is  com- 
menced. 

1580.  "  Having  proved,"  continues  Dr.  0.  "  that  the  loss  which 
the  child  sustains,  by  the  deprivation  of  the  living  principle,  is  so 
extremely  small  as  almost  to  vanish  to  nothing,  and  that  its  bodily 
sufferings  in  the  act  of  deprivation  are  absolutely  none,  it  becomes 
proper,  next,  to  inquire  what  is  the  value  of  an  unborn  child  to 
its  parents  and  to  the  community."  p.  42. 

1581.  "  Before  the  birth  of  the  chWd, parental  affection  has  not 


CEPHALOTOMY.  563 

taken  place^  which,  for  tlie  wisest  and  best  purposes,  is  one  of 
the  strongest,  the  most  universal,  and  perhaps,  the  most  uncon- 
trollable passions  of  the  female  breast;  often  changing,  even  in 
the  subordinate  parts  of  the  creation,  the  very  nature  of  a  timid 
mother,  into  that  of  a  ferocious  animal.  Disappointment  of  ex- 
pected pleasure  only,  not  the  loss  of  any  object  of  this  powerful 
passion,  or  the  loss  of  any  actual  enjoyment,  is  the  sacrifice  the 
unhappy  parent  makes  on  this  occasion."  p.  43. 

1582.  We  are  of  opinion,  that  Dr.  0.  is  far  from  having /;rove^, 
(except  to  himself,)  that  which  he  so  complacently  slates  he  has 
done,  (1579.)  And,  if  he  had  really  "proved"  that  which  we 
think  he  has  merely  taken  for  granted,  it  still  would  have  no  bearing 
upon  the  subject — the  degree  of  sensibility  of  the  child  while  in 
utero,  or  whether  it  possess  any,  is  not  the  question,  as  I  have 
before  declared;  for  neither  view  of  this  question,  should  prove 
a  motive  of  itself  to  the  operation;  nor  should  either  deter  from 
it;  for  this  point  must  be  settled  upon  other  principles. 

1583.  But  where  Dr.  0.  learned  that  parental  affection  did  not 
exist  before  birth;  is  difficult  to  say;  for  I  must  declare,  and  I  do 
this  without  fear  of  contradiction,  that  the  affection  of  the  parent 
is  strong,  nay,  oftentimes  very  strong,  for  the  child  while  in  utero 
— and  if  any  accident  befall  it,  a  sorrow,  and  sometimes  of  a  deep 
kind,  is  for  a  long  time  indulged — I  have  known  two  instances 
of  protracted,  and  deep-seated  gloom,  follow  the  birth  of  still- 
born children;  and  in  one,  it  was  not  removed  until  a  subsequent 
pregnancy  gave  promise  of  a  more  fortunate  result;  the  other 
gradually  yielded  to  time,  and  change  of  scene. 

1584.  It  would  be  idle  to  say  that  these  were  not  cases  of  dis- 
appointed or  lacerated  affection,  but  the  mere  privation  of  a  pro- 
mised or  anticipated  pleasure.  Besides,  Dr.  0.  tells  us,  that  "pa- 
rental affection"  converts,  in  the  brute,  "the  timid  mother  into 
the  ferocious  animal;"  from  whence  arises  this  recklessness  of 
danger  in  the  "timid  mother,"  in  defence  of  her  offspring,  when 
she  exposes  herself  to  death,  and  often  meets  it  fearlessly  in  at- 
tempting to  protect  it.  What  anticipation  of  future  or  "expect- 
ed pleasure"  exists  in  them?  there  are  not,  nor  cannot  be,  any 
promised  joys  here;  they  look  not  forward  for  such  reward;  yet 
they  unceasingly  display  affection  and  courage,  that  might  put  to 
shame  some,  who  5/iot</^  derive  delight  from  offspring.  Dr.  0. 
could  not  have  been  a  father. 

1585.  Dr.  0.  pursues  this  subject  by  observing,  "had  parental 


.'ifil  n^PHALOTOMT. 

nffection  commenced  at  the  time  of  conception,  or  when  tlie  em- 
bryo is  first  formed;  and  had  it  continued  increasing  during  ges- 
tation, as  the  foetus  advanced  in  growth,  by  the  time  of  birth  the 
passion  would  have  been  mature,  and  its  influence  most  power- 
ful, and  the  mother's  sufferings  would  have  been  greatly  aggrava- 
ted by  the  loss  of  a  beloved  child."  And  is  this  not  precisely 
what  happens  in  a  large  proportion  of  cases?  Who  has  not  wit- 
nessed the  joy  of  a  mother  at  the  first  evidence  she  has  that  her 
child  lives  within  her?  Who  has  not  witnessed  the  growing  af- 
fection of  the  parent  as  gestation  advances?  and  who  has  not  ob- 
served the  sorrow,  when  all  this  maternal  solicitude  has  proved 
unavailing?  What  motive  governs  the  mother,  when  she  submits 
to  the  Caesarean  operation,  or  yields  to  the  section  of  the  pubes? 
Love,  unbounded  love  for  her  unhappy  ofispring!  And  who  that 
has  witnessed  the  dreadful  operation  of  the  crotchet,  cannot  bear 
testimony  to  the  agony  of  the  mother  for  the  loss  of  her  unborn 
child?  If  these  things  were  denied  by  Dr.  O.  I  must  repeat,  he 
is  no  father. 

1586.  Dr.  O.  goes  farther;  he  declares,  "such  a  passion,  (ma- 
ternal affection,)  could  not  be  directed  to  any  useful  purpose,  du- 
ring the  existence  of  the  child  in  the  uterus;  nature,  who  never 
performs  works  of  supererogation  either  in  tlie  physical  or  moral 
world,  has  not  yet  kindled  it  in  the  mother's  breast  ;  it  begins 
only  with  birth:  and  parents  in  general  ma}',  I  think,  be  literally 
said  to  suffer  nothing,  by  the  loss  of  an  unborn  child." 

1587.  To  this  I  will  briefly  state,  that  maternal  affection  is 
constantly  necessary  from  the  moment  conception  is  believed  to 
have  taken  place,  until  the  final  expulsion  of  the  child  from  the 
uterus.  Were  a  woman  not  influenced  by  strong  afiection  to  the 
protection  of  her  child  while  in  utero,  she  would  have  no  reward  for 
the  many,  and-oftentimes  severe  sufferings,  and  privations,  during 
that  period;  and  were  not  this  love  for  the  child  paramount  to 
every  other  feeling,  as  a  general  rule,  there  would  be  no  motive 
for  its  preservation — carelessness  or  design,  might  constantly 
circumvent  tlie  great  object  of  creation.  And,  with  respect  to 
his  conclusion,  I  appeal  to  the  whole  world  for  its  refuta- 
tion. 

1588.  Again,  the  Dr.  says,  "to  society,  likewise,  the  loss  of 
any  individual  child  must  be  exceedingly  small,  when  it  is  known 
by  daily  observation,  what  great  numbers  of  children  are  still- 
born, or  die  without  such  violence  before  birth;  when  it  is  like- 


CEPHALOTOMY.  565 

wise  known,  how  very  precarious  is  the  chance  of  a  child's  liv- 
ing two  years;  but  how  most  of  all  precarious,  is  its  arrival  at 
that  period  of  life,  when  it  can  be  of  any  service  to  its  fellow 
creatures,  or  even  participate  itself  in  the  enjoyments  of  the 
world"  (p.  45.) 

1589.  To  me  it  is  truly  a  matter  of  surprise,  that  the  various 
contingencies  which  may  prevent  a  child  from  being  born  alive; 
from  its  continuing  two  years  upon  earth  after  birth;  or  from 
arriving  at  manhood;  should  be  employed  as  an  argument  against 
the  value  of  its  life.  It  appears  to  me,  that  it  should  have  a 
diametrically  opposite  bearing;  for,  were  the  birth  of  a  still-born 
child  a  rare  occurrence ;  were  it  almost  certain  that  children 
should  arrive  at  the  age  of  two  years;  their  arrival  at  puberty, 
or  beyond  it,  nearly  sure;  the  occasional  loss  of  a  child  by  em- 
bryulcia,  or  any  other  violence,  would  then  be  but  little  felt: 
but  when  such  violences  are  to  add  victims  to  the  already  too 
long  list  of  human  deaths,  they  must  be  considered  as  evils; 
wliatever  may  be  the  necessity  for  employing  them. 

1590.  I  admit,  that  society  suffers  but  little  loss  on  account 
of  "any  individual  child,"  so  long  as  the  loss  is  confined  to  that 
individual  child;  but  when  this  indifference  to  "individual"  life, 
goes  beyond  a  single  instance,  we  cannot  foretell  where  it  may 
stop — it  may  extend  to  thousands;  for  thousands  are  but  aggre- 
grated  units. 

1591.  Dr.  0.  concludes  this  remarkable  essay  in  these  words: 
« In  estimating  the  value  of  the  life  of  the  unborn  child  at  so  low 
a  rate,  I  most  earnestly  request  the  medical  reader  will  never 
lose  sight,  that  it  is  only  in  comparison  with  the  mother,  or  when 
the  child's  life  is  put  in  competition  with  her  safety,  that  any  ar- 
guments on  this  score  are  entitled  to  the  smallest  weight.  It  is 
for  the  preservation  of  the  mother's  life  only,  that  we  can  justify 
the  practice  here  recommended  and  insisted  on."  (p.  45.) 

1592.  It  does  not  appear  to  me  at  all  necessary,  that  the  value 
of  the  child's  life  should  have  so  low  an  estimate,  in  order  to  liave 
arrived  at  the  above  conclusion — it  was  every  way  sufficient  for 
the  purpose  for  which  the  comparison  was  instituted,  that  the 
value  of  the  mother  should  have  been  deemed  greater.  I  fear, 
Dr.  0.  is  chargeable  with  having  done  mischief,  by  the  view  he 
has  taken  of  this  subject;  for  I  do  know  full  well,  he  has  been 
quoted  in  support  of  '■<■  cephalotomy,"  where  its  necessity,  in  my 
estimation,  was  far  from  being  absolute. 


5G6  CEPHALOTOMY. 

1593.  As  no  possible  advantage  can  result  from  the  manner 
in  which  Dr.  0.  has  treated  this  inquiry,  it  is  to  be  lamented  that 
it  was  ever  agitated,  since  the  subject  has  not  derived  the  small- 
est elucidation  from  it;  though  it  may  occasion  serious,  and  often- 
repeated  mischief.  Had  he  treated  this  matter  differently,  and 
shown  how  precious  the  life  of  a  child  is;  yet,  however  precious, 
that  that  of  the  mother  is  still  more  so;  and  that  nothing  but  im- 
perious necessity  should  be  permitted  to  institute  a  comparison 
of  their  respective  values,  when  one  or  other  must  be  the  sacri- 
fice, it  would,  in  my  opinion,  have  more  certainly  served  the 
cause  of  humanity,  and  much  more  effectually  have  promoted  the 
interest  of  science. 

1594.  I  shall  pursue  this  subject  a  little  firther,  by  offering  a 
few  remarks  upon  "  Elizabeth  Sherwood's  case"  by  which  Dr. 
0.  supposes  he  has  ascertained  the  minimum  opening  of  a  pel- 
vis, through  which  a  child  at  full  time  ma}^  be  extracted  by  the 
crotchet. 

Observations,  ^-c.  on  Elizabeth  Sherwood's  Case,  as  related 
by  Dr.  Osborn. 

1595.  The  whole  of  Dr.  Osborn's  arguments  on  the  subject 
of  "embryulcia,"  are  intended  to  show.  1st.  that  this  operation 
decidedly  merits  the  preference  over  the  Cesarean  section,  where- 
ever  there  is  an  inch  and  a  half  of  opening  at  the  superior  strait; 
and  2d.  that  it  is  never  justifiable  to  perform  the  latter  operation, 
when  a  diameter  of  this  size  really  exists:  these  positions  he  at- 
tempts to  illustrate,  by  the  recital  of  the  melancholy  case  of 
Elizabeth  Sherwood. 

1596.  The  comparative  merits  of  these  two  operations  should 
alone  be  decided  by  the  advantage  one  may  possess  over  the 
other;  and  this  advantage  determined  by  the  general  results  of 
the  respective  operations.  Dr.  0.  condemns  without  reserve  the 
Caesarean  section,  as  consigning  the  woman  to  "  inevitable  de- 
struction," while  a  number  of  equally  respectable  men,  recom- 
mend it  in  preference  to  the  crotchet;  affirming  it  to  be  equally 
safe,  and  decidedly  more  advantageous,  as  the  child  has  a  chance 
of  life.  I  shall,  however,  reserve  my  consideration  of  this  sub- 
ject, until  I  speak  of  the  Caesarean  operation  itself;  and  shall 
now  proceed  to  make  a  few  observations  upon  the  case  on  which 


CEPHALOTOMY.  567 

Dr.  0.  is  determined  to  rely,  for  the  support  of  his  opinions  upon 
this  point. 

1597.  Elizabeth  Sherwood's  was  a  case  of  extreme  deformity; 
she  was  but  forty-two  inches  in  height — she  could  neither  move 
nor  stand,  but  by  the  aid  of  crutches.  In  her  27th  year  she  be- 
came with  child,  and  was  admitted,  for  the  purposes  of  delivery, 
into  the  Store  Street  Hospital,  London.  After  her  labour  com- 
menced, it  was  first  contemplated  to  perform  the  Ca^sarean  ope- 
ration, as  "  there  ivould  be  a  certainty  of  preserving  one  life,  at 
IcastJ^  But  this  humane  and  proper  determination  was  aban- 
doned, it  would  seem,  with  as  much  facility  as  cruelty,  because 
Dr.  0.  and  his  friends  "  were  rather  disposed  to  believe,  that  the 
child  was  dead." 

1598.  Not  a  single  reason  is  given  for  the  ^'disposition  to  believe 
the  child  to  be  dead'^ — nor  were  they  satisfied  themselves  that  this 

'was  the  case,  from  the  doubtful  and  careless  way  Dr.  0.  has  ex- 
pressed himself  on  this  point.  It  was  due  to  the  public,  to  the 
profession,  and  to  themselves,  to  have  stated  at  large,  the  grounds 
of  this  belief;  and,  if  they  were  well  founded,  the  operation,  which 
was  soon  after  commenced,  would  certainly  have  been  justifiable; 
if  the  child  vvere  not  dead,  it  might  admit  of  doubt — however,  the 
opening  of  the  head  was  decided  upon;  and  the  child  was  ulti- 
mately delivered.  It  is  upon  this  delivery,  and  the  state  of  the 
pelvis,  as  declared  by  Dr.  0.  I  propose  to  offer  a  few  remarks; 
remarks,  which  suggested  themselves  by  carefully  reading  the 
case,  but  which  created  strong  doubts  of  the  fidelity  of  the  repre- 
sentation;* for  if  the  case  be  faithfully  related,  it  almost  disposes 
us  to  say,  he  had  performed  impossibilities. 

1599.  Dr.  0.  commences  his  account  of  the  examination  of  this 
poor  woman,  by  stating,  ''that  immediately  upon  the  introduction 
of  the  finger,  he  perceived  a  tumour  equal  in  size,  and  not  very 
unlike  in  the  feel  to  a  child's  head."  This  was  the  projection  of 
the  sacrum,  and  so  advanced  towards  the  pubes,  as  to  leave  but  a 
space  of  three-quarters  of  an  inch.  On  the  left  side  of  this  projec- 
tion, towards  the  ilium,  there  was  a  distance  of  about  two  inches 

*  In  this  remark,  I  am  by  no  means  to  be  understood  to  insinuate,  that  IcaU 
into  question  the  veracity  of  Dr.  O.  I  merely  suggest,  that  as  mathematical 
precision  could  not  be  arrived  at,  an  error  in  estimate  may  have  crept  into  the 
account;  since,  from  the  g'reat  interest  which  was  excited,  as  well  as  the  confu- 
sion consequent  upon  an  operation  under  such  circumstances,  extreme  accura- 
cy could  not  perhaps  reasonably  be  expected. 


568  CEPHALOTOMY. 

and  a  half;  leaving  a  space  of  three-fourths  of  an  inch.  On  the 
rio-ht  side,  there  was  rather  more  than  two  inches;  with  an  open- 
ing in  its  widest  part  of  one  inch  and  three-quarters,  gradually, 
however,  narrowing  each  way — ^so  much  of  the  pelvis. 

1 600.  From  the  data  here  given,  both  the  superior  and  inferior 
straits  must  have  been  faulty — the  lovver,  I  presume,  to  such  a 
degree,  (though  nothing  of  the  kind  is  mentioned,)  that  the  hand 
could  not  be  introduced;  or  at  least,  not  easily;  since  the  projec- 
tion of  the  sacrum  was  '■'■  in  size  and  feel  like  a  child's  head;" 
consequently,  there  must  have  been  extreme  difficulty  in  ascer- 
taining the  situation  of  the  head,  either  as  regards  its  position  or 
firmness;  for  the  finger  could  not  reach  so  high,  without  the  in- 
troduction of  the  hand. 

1601.  He  next  informs  us,  "the  os  uteri,  though  but  little  di- 
lated, was  soft  and  flabby;"  "  the  membranes  were  not  yet  broke, 
but  with  some  difficulty  he  perceived  the  child's  head,  through 
them,  situated  very  high  above  the  projection."  From  whence 
did  the  difficulty  to  touch  the  child's  head  arise?  its  remoteness — 
the  hand  then  could  not  have  been  introduced  into  the  vagina,  or 
this  ''difficulty"  would  not  have  existed — in  an  examination  so 
important  to  the  welfare  of  his  patient,  it  is  presumable  that  Dr. 
0.  would  have  introduced  his  hand  had  this  been  practicable.  I 
shall  employ  this  conclusion  presently. 

1602.  Next  morning  "no  alteration  had  taken  place  either  in 
the  state  of  the  os  uteri,  or  the  position  of  the  child's  head."  The 
membranes  had  given  way  during  the  night.  Dr.  0.  now  availed 
himself  of  the  opinions  of  several  celebrated  accoucheurs  and  sur- 
geons, neither  of  whom,  gave  greater  dimensions  to  the  upper 
strait  than  had  been  given  by  him;  some  even  less.  The  Caesa- 
rean  operation  was  first  suggested;  but  abandoned,  as  stated  above, 
without  any  apparent  good  reason. 

1603.  Dr.  0.  now  commenced  the  operation  of "  embryulcia," 
and  says,  "  even  the  first  part  of  the  operation,  which,  in  general, 
is  sufficiently  easy,  was  attended  with  considerably  difficulty,  and 
sojne  danger?^'  from  whence  arose  the  danger?  the  wounding  of 
the  soft  parts  of  the  mother,  I  presume.  "  The  os  uteri  was  but 
little  dilated,  and  was  awkwardly  situated  in  the  centre,  and  most 
contracted  part  of  the  brim  of  the  pelvis" — that  is,  where  there 
was  but  a  space  of  three-fourths  of  an  inch.  "  The  child's  head 
lay  loose  above  the  brim,  and  scarce  within  reach  of  the  finger, 
nor  was  there  any  suture  directly  opposite  to  the  os  uteri."  Would 


f'KPIIALOTOMV.  569 

it  not  seem  to  require  an  unusual  perfection  in  the  tact,  under  such 
circumstances,  to  satisfactorily  determine  there  was  no  suture  op- 
posite the  OS  uteri? — probably  there  was  none;  but  to  ascertain 
and  satisfy  ourselves,  as  Dr.  0.  appears  to  have  done,  would  re- 
quire, as  I  have  just  stated,  an  uncommon  degree  of  nicety  of 
touch;  for  it  must  be  borne  in  mind,  there  was  no  pressure  at  this 
time  on  the  head  to  make  the  bones  ride  over  each  other,  and  by 
which  the  presence  of  a  suture  might  be  detected  or  even  sus- 
pected; on  the  contrary,  "  the  head  lay  loose  above  the  brim,  and 
scarce  within  reach  of  the  finger." 

1604.  I  grant,  however,  it  is  not  fair  to  suppose  that  one  can- 
not do  that,  which  another  would  find  impossible.  Yet  I  must  con- 
sider myself  safe  in  the  remark,  that  a  little  pressure  from  the 
finger,  and  some  resistance  from  the  head,  would  have  been  essen- 
tial to  the  discovery  of  a  suture,  had  one  even  been  there. 

1605.  Dr.  O.  proceeds  to  say,  "  he  desired  an  assistant  to  com- 
press the  abdomen  with  sufficient  force  to  keep  the  head  in  contact 
with  the  brim  of  the  pelvis,  so  as  to  prevent  its  receding  from  the 
scissors,  upon  the  necessary  pressure  of  the  point,  to  make  the 
perforation;  I  introduced  them,  with  the  utmost  caution  through 
the  OS  uteri,  and,  after  repeated  trials,  at  length  succeeded  in  fix- 
ing the  point  into  the  sagital  suture,  near  the  posterior  fontanelle." 
All  this  is  so  very  circumstantial,  as  to  excite  wonder,  in  no  small 
degree — first,  there  was  no  suture  opposite  the  os  uteri;  second, 
the  OS  uteri  was  in  the  centre  of  the  projection,  and  not  well  dilated, 
and  at  a  part  where  there  was  a  space  but  of  three-quarters  of 
an  inch;  third,  the  head  was  forced  to  keep  its  situation,  that  the 
scissors  might  enter;  in  which,  after  several  attempts,  he  suc- 
ceeded to  penetrate  a  suture,  and  that,  "  the  sagital  suture  near 
the  posterior  fontanelle! !"  Now,  I  think  I  do  not  disparage  the 
tact  of  any  man,  either  living  or  dead,  when  I  say,  that  none  other 
than  Dr.  0.  could  have  told  into  which  of  the  sutures  he  plunged 
his  scissors  under  the  same  circumstances. 

1606.  Di%  0.  now  tells  us  of  some  of  the  difiiculties  attending 
his  enterprise,  arising  from  his  attempts  to  break  down  the  bones 
of  the  cranium:  confessing  that  "the  instrument  at  first  invaria- 
bly slipped,  as  often,  and  as  soon  as  it  was  fixed,  or  at  least  be- 
fore he  could  exert  sulTicient  force  for  this  purpose."  It  would 
be  instructive  to  know  what  parts  of  the  mother  received  the 
point  of  the  crotchet  ''when  it  slipped;"  for  we  are  forbidden, 
from  the  description  of  the  pelvis  itself,  to  suppose  the  point  was 

72 


570  CEPHALOTOMY. 

guarded  by  the  other  hand,  since  it  could  not  possibly  be  in- 
troduced profitably,  (1601)  if  at  all,  into  the  vagina,  for  this  pur- 
pose. 

1607.  At  length  the  Doctor  succeeded  in  firmly  fixing  the  in- 
strument, even  into,  he  believes,  the  foramen  magnum,  of  which 
he  availed  himself  "  to  the  utmost  extent,  slowly,  gradually,  but 
steadily  increasing  the  force,  till  it  arrived  to  that  degree  of  vio- 
lence, which  nothing  could  justify  but  the  extreme  necessity  of 
the  case."  I  would  ask  what  must  have  been  the  condition  of  the 
soft  parts  against  which  this  force  was  exerted?  I  have  known 
mucli  less  force  than  that  ''degree  of  violence  which  nothing 
could  justify  but  the  extreme  necessity  of  the  case,"  followed  by 
severe,  and  even  hazardous,  if  not  fatal  consequences.  But  in  this 
case  Dr.  0.  was  ordained  to  triumph;  over  not  only  nearly  insu- 
perable difficulties,  but  also  over  the  consequences  of  the  ex- 
treme violence  he  was  obliged  to  use  to  accomplish  the  delivery. 
In  my  hands,  after  such  violence,  I  am  disposed  to  believe,  nay, 
almost  sure,  the  woman  would  have  died;  not  so,  Elizabeth  Sher- 
wood; for  she  was  reserved  for  another  trial  of  a  similar  kind, 
and  not  being  under  the  care  of  Dr.  0.  she  died. 

160S.  But  notwithstanding  this  great  exertion  of  force,  it  was 
urged  to  no  profitable  purpose;  he  therefore  abandoned  the  idea 
of  breaking  down  the  base  of  the  cranium  by  the  crotchet,  and 
then  most  happily  succeeded  in  effecting  by  address,  that  which 
could  not  be  overcome  by  force;  for,  by  a  little  management 
with  two  fingers,  he  was  fortunate  enough  to  place  the  base  of  the 
skull  edgeways,  which  permitted  it  to  pass,  by  a  continuation  of 
the  force  applied  to  it.  Now,  only  let  us  consider  how  wonderful 
Dr.  O.'s  achievement  in  this  instance  must  have  been; — first,  he 
accomplishes  the  penetration  of  the  skull,  and  the  evacuation  of 
the  brain;  next,  he  succeeds  in  detaching  by  the  crotchet  every 
part  of  the  bones  from  the  cranium,  except  its  base,  through  an 
aperture  of  one  inch  and  three-quarters  in  width  in  its  greatest 
capacity,  and  this  gradually  diminishing;  it  had,  however,  rather 
more  than  two  inches  in  length.  Though  this  removal  of  the 
bones  is  not  exactly  expressed,  it  must  be  so  understood,  or  he 
could  not  have  turned  the  base  of  the  cranium  "  edgeways."  Soon 
after  this,  his  difficulties  were  at  an  end,  by  the  successive  delive- 
ry of  portions  of  the  child's  body,  &.c. 

1609.  This  case,  from  its  success,  is  to  serve  as  an  instance  of 
the  triumph  of  skill  and  of  perseverance  over  the  greatest  possi- 


CEPHALOTOMY.  571 

ble  difficulties  which  can  he  well  encountered  in  a  labour;  and 
one  as  proving  clearly  and  distinctly  the  superiority  of  the  crotch- 
et over  the  Caesarean  operation,  though  the  woman  endured  in- 
quisitorial tortures  with  "  surprising  firmness  and  fortitude"  for 
three  hours,  and  most  miraculously  escaped  with  her  life!!  I  say 
miraculously  escaped — for  who  could,  or  who  would  anticipate 
success  from  such  violence,  under  such  circumstances?  I  am  per- 
suaded, that  neither  Dr.  0.  nor  his  compeers  looked  forwartl  to 
such  an  issue,  at  the  moment  of  its  performance;  and  it  is  nothing 
more,  if  the  whole  be  faithfully  related,  than  an  instance  of  how 
much  the  human  body  can  bear,  and  not  an  example  from  which 
eitlier  the  young  or  the  old  practitioner,  can  safely  dravv  conclu- 
sions in  its  favour.  I  have  seen  death  follow  the  use  of  the  crotch- 
et, where  there  was  neither  the  same  degree  of  deformity,  nor  the 
same  violence  necessary  to  effect  delivery;  and  where  I  believe 
as  little  injury  was  sustained  by  the  soft  parts,  as  the  nature  of 
things  permitted.  I  shall  again  have  occasion  to  speak  of  the 
risks  of  embryulcia. 

1610.  The  mode  of  performing  embryulcia  is  sufficiently  sim- 
ple, if  we  merely  regard  the  opening  of  the  head,  and  the  break- 
ing down  the  texture  of  the  brain ;  but  the  extraction  of  the 
bones  in  a  confined  pelvis  is  replete  with  difficulty,  if  we  are  suffi- 
ciently mindful  of  doing  no  injury  to  the  soft  parts  of  the  mother; 
and  on  this  almost  everything  depends.  The  head,  if  movable 
at  the  superior  strait,  should  be  fixed,  if  the  uterus,  after  the 
evacuation  of  the  waters,  does  not  contract  with  sufficient  force 
to  do  this — the  point  of  Smellie's  scissors  must  then  be  made  to 
penetrate  the  cranium;  and  if  a  suture  can  be  found,  it  should  al- 
ways be  preferred — when  they  are  introduced  as  far  as  their 
shoulders  will  permit,  the  handles  are  to  be  separated  to  some 
distance,  and  rotated  in  that  situation,  until  an  opening  of  suffi- 
cient size  to  admit  the  crotchet  be  made — when  this  is  done,  the 
crotchet  must  be  passed  into  it,  and  the  brain  broken  down  with 
it.  It  is  never  necessary  to  use  any  other  instrument  for  this 
purpose.*  When  this  is  done,  the  point  of  the  crotchet  is  to  be 
fastened  in  the  nearest  portions  of  bone;  and  it  must,  if  practica- 
ble, be  guarded  by  the  fingers  of  the  other  hand  against  slipping 
— if  the  bones  collapse  readily,  and  the  pelvis  be  not  much  con- 
tracted, the  head  may  pass  nearly  entire;  but  if  it  is  necessary 

*  Dr.  Davis'  craniotomy  forceps  are  said  to  facilitate  this  operation,  ver^' 
much — of  this  we  can  say  nothing-,  practically. 


572  CiESAREAN  OPERATION. 

to  employ  much  force,  the  portions  of  bone  on  which  the  crotchet 
is  fixed,  will  successively  give  way— the  detached  portions  must 
be  carefully  removed  from  time  to  time ;  taking  care  not  to  wound 
the  vagina  in  extracting  them. 

1611.  Dr.  Osborn  recommends  the  early  use  of  this  instrument, 
when  it  is  necessary  to  employ  it;  and  to  permit  the  woman  to 
rest  for  thirty  hours,  that  putrefaction  may  take  place  in  the  child, 
as  this  will  very  much  facilitate  its  extraction.  Should  the  child 
have  been  dead  some  time  before  the  operation,  we  need  not  wait 
so  long,  or  perhaps  not  at  all.  I  agree  fully  with  Dr.  Osborn,  that 
the  crotchet  should  be  used  on  the  inside  of  the  cranium,  for  the 
extraction  of  the  head. 

Sect.  IV.— ^.  Of  the  Cesarean  Operation. 

1612.  This  operation  is  proposed  as  a  means,  in  cases  of  ex- 
treme deformity,  to  preserve  the  life  of  the  child,  or  the  mother, 
or  both.  The  history  of  this  operation  offers  proofs  of  success, 
as  well  as  of  failures;  and  it  appears  to  be  agreed  upon  all  hands, 
that  nothing  can  justify  its  performance,  but  such  cases  as  would 
require  the  use  of  the  crotchet  for  their  termination — the  ques- 
tion then  resolves  itself  into  this;  under  extreme  deformity,  by 
which  of  the  operations,  will  the  patient  and  society  be  most 
benefited? 

1613.  From  an  attentive  consideration  of  both  of  these  opera- 
tions, I  am  in  fiwour  of  the  Ca^sarean  operation,  wherever  there 
would  be  an  absolute  necessity  to  the  use  of  the  crotchet  for  the 
delivery  of  the  chi^d;  and  for  the  following  reasons: 

1614..  First,  because  the  child  must  inevitably  be  destroyed  by 
the  use  of  the  crotchet. 

1615.  Second,  because,  from  all  I  can  learn,  and  all  that  I  have 
seen  in  the  employment  of  this  instrument  in  cases  of  extreme 
deformity,  (though  I  confess  my  own  experience  in  this  business 
to  be  very  limited,)  the  risk  appears  to  be  very  great  to  the  wo- 
man;* and,  as  just  stated,  certainly  fatal  to  the  child. 

1616.  Third,  because  there  are  cases  in  which  it  is  impossible, 
at  least  in  my  opinion,  even  not  excepting  such  as  may  have  an 
inch  and  a  half  in  the  antero-posterior  diameter,  to  deliver  with 
the  crotchet. 

*  Bauclelocqae,  nephew  to  the  late  celebrated  accoucheur,  says  that  more 
than  half  of  the  women  die  who  have  embryulcia  performed. — ArchMs  G6ni- 
raks  de  Midednc;  &c.  torn.  xxL  Od,  1829, 


CESAREAN  OPERATION. 


573 


1617.  Fourth,  because,  where  this  instrument  is  employed, 
under-  the  most  favourable  circumstances  in  which  it  would  be 
justifiable  to  employ  it,  there  is  a  constant  and  a  great  risk  to  the 
mother,  with  the  certain  sacrifice  of  the  child. 

1618.  In  my  remarks  upon  the  choice  of  the  crotchet,  and 
Csesarean  operation,  I  must  always  be  understood  to  have  refer- 
ence to  cases  where  it  is  ascertained,  or  presumable,  that  the 
child  is  living;  for  if  the  child  be  dead,  and  this  satisfactorily 
proved,  then  the  crotchet,  under  a  sufficient  diameter  of  pelvis,* 
should  be  preferred.  See  chapter  on  the  uncertainty  of  the  child's 
death. 

1619.  But  if  the  child  be  dead,  and  the  delivery  impossible  by 
the  crotchet,  the  Ca^sarcan  operation  should  be  proposed. 

1620.  Our  opinions  upon  the  propriety  of  the  Csesarean  ope- 
ration, will  vary  as  we  may  consult  the  British  or  the  continental 
accoucheurs  upon  the  subject — the  former  declaring  its  inva- 
riable failure  to  the  mother,  though  sometimes  fortunate  to  the 
child;  while  the  latter  assures  us,  it  frequently  succeeds  with  both. 
Whence  arises  this  difference  in  result? 

1621.  M.  Tenon  declared  to  Dr.  Ga.rthshore,t  that  in  his  opi- 
nion the  reason  why  it  had  so  seldom  succeeded  in  Great  Bri- 
tain, was  because,  in  that  country,  the  operation  is  almost  inva- 
riably deferred  too  long;  for  the  patient  is  suffered  to  be  almost 
in  articulo  mortis,  before  it  is  undertaken. 

1622.  It  is  no  longer  a  question  among  the  continental  ac- 
coucheurs, which  of  the  two  operations  is  to  be  preferred,  when 
there  is  an  absolute  necessity  for  either.  The  Csesarean  section 
is  almost  exclusively  adopted  ;  and  the  success  attending  it  is  suf- 
ficiently great,  agreeably  to  the  latest  and  best  informed  writers, 
to  warrant  this  preference.  Though  the  practice  hitherto  in  Great 
Britain  has  been  almost  uniformly  fatal,  it  is,  nevertheless,  con- 
sidered a  resource  of  the  art  by  several  of  its  most  eminent  men; 
and  they  fail  not  to  recommended  it,  whenever  delivery  is  imprac- 
ticable by  this  instrument;  and  even  where  it  might  be  effected, 

*  By  a  sufficient  diameter,  I  mean,  where  there  is  at  least  two  inches  in  the 
antero-posterior,  and  at  least  three  and  a  half  in  the  traverse;  below  this,  deli- 
very per  vias  naturales,  I  repeat,  I  believe  to  be  impossible.  And  it  is  a  moot 
point,  whether,  with  a  diameter  of  full  two  inches,  &c.  the  risk  to  the  mother 
is  not  as  great  as  the  Ceesarean  section;  yet  in  this  instance,  and  with  a  dead 
child  the  crotchet  would  merit  the  preference,  as  it  is  apparently  the  less  se- 
vere operation,  and  one  that  would  more  certainly  meet  the  pubhc  approbation. 

f  Hull's  letter  to  Simmons.     See  note  to  par.  1615. 


574  r^,SAREAN  OPERATION. 

but  perhaps  at  an  equal  hazard  to  the  woman.*  Drs.  Hall  and 
Denman,  and  also  Mr.  Burns,  may  be  considered  as  good  autho- 
rity upon  this  subject. 

1623.  Notwithstanding  all  that  Dr.  Osborn  has  declared  in 
favour  of  the  safety  of  the  crotchet  in  extreme  deformity  of  the 
pelvis,  he  appears  to  have  carried  conviction  to  the  minds  of  but 
few;  and  his  unqualified  assertion  that  the  Csesarean  operation 
is  "  inevitable  destruction"  to  the  mother,  is  almost  daily  contra- 
dicted by  the  promulgation  of  successful  cases.  That  it  is  an 
operation  of  great  hazard,  no  one  will  deny;  but  that  is  necessa- 
rily fatal,  has  been  contradicted  by  success,  hundreds  of  times. 

1624.  On  the  continent  of  Europe,  this  operation  is  resorted 
to  at  an  early  period  of  the  labour;  before  the  woman  is  either 
exhausted  by  the  continuance  of  unavailing  pains,  or  is  in  a  state 
almost  of  gangrene  from  fever.  The  uterus  is  cut  before  it  is 
inflamed,  and  the  child  is  extracted  before  it  has  expired;  and 
the  attempt  to  save  both  mother  and  child  is  sometimes  crowned 
with  the  happiest  result.  Is  there  not,  then,  strong  reason  to  be- 
lieve, that  were  the  same  independence  exercised  by  the  surgeons 
of  Great  Britain  towards  the  poor  woman  who  suffers  from  defor- 
mity, the  same  fortunate  issue  would  happen  as  in  France  and 
Germany,t  and  as  frequently?     I  am  by  no  means  of  opinion  that 

*  Dr.  Osborn,  it  would  seem,  had  failed  to  convince  his  friend  and  associate, 
Dr.  Denman,  of  eitlier  the  superior  safety  of  the  crotchet  in  extreme  deformity, 
or  of  the  invariable  fatahty  of  the  Csesarean  section;  for  he  has  not  quoted 
him  as  authority  for  the  first,  nor  coincided  with  him  in  the  latter.  Dr.  Den- 
man decidedly  favours  the  Cesarean  section,  under  circumstances  wherein  Dr. 
Osborn  would  have  proscribed  it.  And  in  some  instances.  Dr.  D.  is  inclined 
to  consider  the  operation  in  a  moral  point  of  view:  he  queries,  "suppose 
a  woman  was  so  unfortunately  fi'amed,  that  she  could  not  possibly  beai-  a  liv- 
ing child  by  any  method  hitherto  known.  The  first  time  of  her  being'  in 
labour,  no  reasonable  person  could  hesitate  to  afford  relief  at  the  expense  of 
her  child:  even  a  second  and  a  third  trial  mig-lit  be  justifiable  to  ascertain  the 
fact  of  the  impossibility.  But  it  might  be  doubted  in  morals,  whether  childi-en 
should  be  begotten  under  such  circumstances,  or  whether,  after  a  solemn  deter- 
mination she  cannot  beai-  a  living  child,  a  woman  be  entitled  to  have  a  number 
of  children  destroyed  for  the  purpose  of  saving  her  life;  or  whether,  after  many 
trials,  she  ought  to  submit  to  the  Cjesarean  operation,  as  the  means  of  preser- 
ving the  child  at  the  risk  of  her  own  life,  if  she  will  submit  to  have  children 
under  such  circumstances.  This  ought  to  be  considered." — Introduction, 
Francis's  ed,  p.  423. 

f  In  both  these  countries,  this  operation  has  been  repeatedly  performed, 
with  the  most  entire  success;  and  we,  recently,  have  it  in  our  power  to  con- 
^^ratulate  the  profession  upon  this  operation  being  successfully  performed  both 


CiESAREAN   OPERATION.  575 

the  failures,  in  England  especially,  have  been  owing  to  climate — 
procrastination,  is  the  cause  of  the  evil.  An  interesting  case  is 
related  in  Rust's  Magazine,  which  we  shall  transcribe. 

Caroline  Bechang  was  admitted  into  Graafe's  Clinicum,  in  an 
advanced  stage  of  pregnancy;  she  was  thirty  years  old;  much  de- 
formed by  rickets,  and  measuring  four  Rhenish  feet  in  height. 
On  the  20th  September,  after  having  been  five  days  in  labour  at 
the  full  period,  pains  severe,  and  the  os  uteri  dilated,  she  consent- 
ed to  the  Caesarean  operation. 

A  little  after  two  o'clock,  Graafe  passed  the  forefinger  of  his  left 
hand,  immediately  below  the  umbilicus,  and  with  a  large  scalpel 
made  an  incision  downwards  in  the  linea  alba,  to  within  an  inch 
of  the  pubis;  dividing  the  entire  parietes,  and  even  penetrating 
the  substance  of  the  uterus.  A  second  incision  was  made  to 
penetrate  the  uterus,  and  expose  the  placenta,  which,  as  had  been 
anticipated,  was  found  upon  the  fore  part  of  the  fundus  of  this  or- 
gan. The  assistants  now  firmly  compressed  the  edges  of  the  di- 
vided abdominal  parietes  upon  the  uterus  itself,  to  prevent  the 
protrusion  of  the  intestines;  in  this  they  succeeded;  and  Graafe 
carried  his  hand  in  a  moment  to  the  fundus;  separated  the  pla- 
centa with  his  fingers  and  thumb,  and  then  withdrew  it  and  the 
child  almost  together.  The  child  was  very  active,  and  cried  lus- 
tily. The  uterus  immediately  and  suddenly  contracted,  and  the 
bleeding  was  inconsiderable;  for  not  more  than  twelve  ounces 
were  lost,  and  no  ligature  was  required.  The  whole  operation 
was  completed  in  four  minutes  and  a  half.  The  wound  was  se- 
cured by  three  broad  sutures  and  adhesive  plasters,  assisted  by  a 
bandage  round  the  abdomen.  The  child  weighed  six  pounds, 
and  was  well  formed. 

During  the  operation  the  patient  was  sick,  and  vomited  a  little. 
In  two  hours  she  had  pain  and  fever:  V.  S.  3xij.  draught  with 
ten  drops  of  the  aqua  lauro  cerasi  was  given,  and  it  was  repeated 
in  a  few  hours.  The  patient  passed  a  quiet  night.  The  symp- 
toms of  pain,  inflammation,  and  fever,  were  threatening  for  some 
days,  but  were  promptly  resisted  by  the  lancet,  by  enemata, 
by  narcotics,  especially  the  lauro  cerasus,  hyosciamus,  by  fo- 
mentations, &c.     By  the  ninth  day,  the  wound  had  cicatrized, 

to  mother  and  child,  in  several  instances,  by  Dr.  Lecher  and  others.  (See  Me- 
dico-Chirur.  Trans.  Vol.  IX.,  &c.  In  France  and  other  parts  of  tlie  continent, 
agreeably  to  Baudelocque,  one  hundred  and  thirty-nine  women  recovered,  out 
of  tvi^o  hundred  and  tliirty  cases.  (See  also  Edin.  Med.  and  Surg.  Jour. 
No.  VI.  New  series.) 


576  CJESAREAN  OPERATION. 

excepting  a  part  near  the  symphysis  pubis;  symptoms  all  fa- 
vourable. 

I'he  lochia  were  discharged  regularly;  and  in  three  weeks, 
she  was  able  to  sit  up,  and  in  three  more  was  quite  well.  Early 
in  November  she  returned  home  with  her  child,  both  in  perfect 
health. 

In  Ferussac's  "  Bulletin  Universal"  for  February,  another  case 
of  the  success  of  this  operation  is  related;  it  proved  fortunate  to 
both  mother  and  child. 

1625.  We  regret  we  are  not  more  particularly  informed  of  the 
circumstances  which  created  the  necessity  of  this  operation;  and 
especially,  the  condition  of  the  superior  opening  of  the  pelvis; 
at  least  as  far  as  could  have  been  ascertained  upon  the  living  sub- 
ject. It  may  however  be  fairly  inferred,  we  presume,  that  the 
diameter  of  the  upper  strait  was  very  small,  from  the  great  facil- 
ity with  which  the  child  was  extracted  through  the  artificial 
opening  made  in  the  uterus. 

1626.  In  addition  to  these  facts,  and  as  a  corroborative  of  the 
repeated  success  of  the  Caesarean  operation,  we  will  extract  a 
case  from  the  "  Bulletin  des  Sciences,"  &c.  for  January,  1S27. 
The  operation  was  attended  with  every  wished-for  success, 
though  performed  on  a  woman  who  had  suffered  upon  a  former 
occasion:  the  cicatrix,  however,  had  always  remained  rather 
weak  ;  or  more  properly,  it  had  never  entirely  healed,  and  it  con- 
tinued to  be  rather  thinner  than  other  portions  of  the  uterus ;  it 
therefore  gave  way  during  labour,  and  subjected  her  to  the  ope- 
ration of  gastrotomy. 

1627.  Two  days  were  allowed  to  pass,  before  this  operation 
was  resorted  to;  it  nevertheless  proved  successful  as  far  as  re- 
gards the  mother,  though  the  child  was  dead.  The  following 
history  cannot  fail  to  be  acceptable,  as  the  lives  of  both  mother 
and  child  were  saved  by  the  timely  and  judicious  performance  of 
the  CcEsarean  operation. 

The  operator  in  the  following  interesting  case  was  Dr.  Midler, 
physician  of  Lowenburg  in  Silesia.  He  was  called  in  July,  1822, 
to  visit  a  woman  who  had  been  two  days  in  labour,  and-whom 
he  found  it  impossible  to  deliver  on  account  of  deformity  of  the 
pelvis.  She  was  thirty-three  years  old,  only  three  feet  tall,  de- 
formed in  many  respects,  the  legs  and  arms  being  disproportion- 
ately short,  the  fore  arms,  thighs,  and  shins  somewhat  crooked, 
the  pelvis  flat  from  before  backwards,  the  chest  well  constructed. 


CJ2SAREAN  OPERATION.  577 

The  gravid  uterus  projected  very  much.  The  whole  body  when 
he  first  saw  her  was  bathed  in  perspiration,  and  she  complained 
less  of  labour  pains,  than  of  insupportable  and  continual  rending 
in  the  lower  pelvis.  The  pulse  was  very  frequent  and  small ; 
and  the  waters  had  been  discharged  for  four-and-twenty  hours. 
On  examining  pa^  vaginam  it  appeared  that  the  superior  outlet 
of  the  pelvis  was  of  the  form  of  a  fissure,  the  length  of  which  from 
the  union  of  the  os  ilium,  and  os pubis  of  one  side  to  the  other 
was  four  inches,  and  the  breadth  at  each  end  between  one  and  a 
half  and  one  and  two-thirds  of  an  inch,  at  the  middle  between 
the  jirominence  of  the  saamm  and  symphysis  pubis  not  above 
two  inches  and  a  sixth.  The  prominence  of  the  sacrum  gave 
the  outlet  the  form  of  a  heart  posteriorly,  and  the  shape  of  the  an- 
terior margin  correspondiiig  with  that  of  the  posterior.  The  os 
uteri  had  disappeared  as  usual,  and  was  close  upon  the  upper'out- 
let  of  the  pelvis.  The  soft  integuments  of  the  child's  head  were 
pressed  as  far  forward  as  the  outlet  would  admit  of,  but  the  head 
was  not  wedged  in.  The  integuments  were  elastic,  and  the  mo- 
ther declared  she  felt  the  movements  of  the  child. 

Natural  delivery  was  manifestly  out  of  the  question;  and  the 
destruction  of  the  child's  head,  though  practicable,  was  fraught 
with  danger  to  the  mother,  and  besides  could  not  be  immediately 
resorted  to  because  the  child  was  alive.  Yet  there  was  no  time 
to  be  lost,  as  the  woman's  strength  was  greatly  exhausted,  and 
farther  delay  exposed  her  to  the  risk  of  speedy  death.  The  Cse- 
sarean  operation,  then,  appeared  to  be  the  only  resource  of  art 
that  remained.  The  patient  readily  gave  her  consent;  and  Dr. 
Midler,  after  the  preparatory  evacuation  of  the  bowels  and  blad- 
der, proceeded  to  perform  it  in  the  following  manner.  At  the  first 
incision  he  cut  through  the  integuments  dovvn  to  the  tendinous  ex- 
pansion of  the  linea  alba,  beginning  an  inch  below  the  navel, 
and  ending  an  inch  above  the  syvijjhysis pubis.  A  small  aper- 
ture was  next  made  into  the  abdomen  near  the  navel,  the  fore 
and  middle  fingers  of  the  left  hand  were  introduced  into  it,  and 
the  scalpel  being  then  passed  between  them,  the  fingers  and  in- 
strument were  carried  downwards  till  the  requisite  opening  was 
completed.  This  was  nine  inches  in  length.  The  uterus  now 
pressed  forcibly  forward,  and  many  large  vessels  could  be  seen 
under  its  glistening  surface.  A  part  of  the  uterus  was  pinched 
up,  and  an  incision,  as  long  as  that  in  the  integuments  would  al- 
low, was  made  through  its  parietes  where  they  were  most  free 
73 


578  CiESAREAN  OPERATIOl!?. 

of  vessels.  Very  little  hasmorrhage  followed  the  wound,  and 
care  was  taken  to  sponge  all  the  blood  away  so  long  as  it  conti- 
nued to  flow.  As  soon  as  the  incision  was  completed,  the  child 
pressed  outwards  with  its  feet  on  the  operator's  left  hand,  and  was 
immediately  removed  without  difficulty.  It  was  alive,  healthy,  vi- 
gorous, and  weighed  seven  and  a  half  pounds.  The  navel  string  was 
secured  in  the  usual  way,  and  the  placenta  soon  afterwards  was  re- 
moved by  introducing  the  hand  previously  cooled  in  water.  Dur- 
ing this  part  of  the  operation,  pressure  was  made  upon  the  abdomen 
to  prevent  the  entrance  of  air  into  the  cavity.  The  wound  was 
now  united  by  adhesive  straps  and  covered  with  charpie;  a  fustian 
belt  was  then  put  on  and  tightened.  At  the  lower  angle  of  the 
wound  an  opening  an  inch  in  length  was  left  without  straps 
for  the  discharge  to  flow  through.  Meanwhile  the  uterus  was 
felt  contracting  in  the  usual  manner  and  formed  a  ball  in  the  left 
flank. 

A  good  deal  of  blood  issued  from  the  vagina  after  the  removal 
of  the  placenta,  and  again  after  the  dressing  of  the  wound  was 
completed.  The  patient  was  directed  to  remain  in  the  supine 
posture,  and  care  was  taken  to  make  every  arrangement  before 
the  operation  to  ensure  perfect  quiet  for  some  time  after  it.  In 
the  evening  there  was  some  fever,  but  no  pain ;  and  during  the 
night  she  slept  none.  Next  day  the  fever  had  increased,  the 
pulse  was  very  frequent,  the  thirst  unextinguishable,  the  pain  of 
the  lower  belly  severe  and  constant,  and  she  had  snatches  of  sleep 
disturbed  by  startings  ;  but  during  the  night  she  slept  well.  Dur- 
ing the  third  day  the  fever  and  pain  were  moderate,  the  abdomen 
a  little  swelled  ;  in  the  evening  the  fever  increased ;  at  night  she 
had  little  sleep.  On  the  morning  of  the  fourth  the  fever  was 
again  moderate.  The  wound  which  had  suppurated,  was  dressed. 
In  the  evening  the  usual  febrile  exacerbation  occurred,  with  in- 
creased swelling,  but  little  pain.  The  straps  having  become 
loose,  they  were  carefully  removed,  and  fresh  ones  applied.  The 
edges  of  the  abdomen  were  hot,  swollen,  and  florid.  The  secre- 
tion of  milk  had  commenced.  At  night  the  patient  slept  well. 
On  the  morning  of  the  lifth  there  was  no  fever,  but  it  returned 
violentlj^  at  mid-day,  with  smarting  of  the  wound,  and  increased 
swelling  of  the  abdomen.  The  fever  moderated,  however,  in  the 
evening,  the  lochia  began  to  flow,  and  the  patient  again  slept  well. 
On  the  sixth  the  abdomen  was  greatly  swollen,  the  purelent 
discharge  great,  the  pain  considerable,  and  the  lochia  more  abund- 


CESAREAN  OPERATION.  579 

ant.  In  the  evening  her  appetite  improved,  and  soup  was  allow- 
ed. The  dressings  were  changed.  On  the  seventh  there  was 
little  or  no  fever,  her  appetite  was  good,  the  pain  and  swelling  had 
abated,  and  the  lochia  more  abundant.  The  wound  was  dressed, 
and  it  was  found  that  two  inches  of  it  next  the  umbilicus  had 
healed.  From  this  time  suppuration  continued  so  profuse  for 
some  days  that  frequent  dressings  were  lequired  daily.  The  ab- 
domen progressively  diminished  in  size;  the  fever  was  incon- 
siderable ;  the  appetite  strong.  On  the  eleventh  tonics  were  ad- 
ministered, the  treatment  having  previously  been  confined  to  the 
occasional  administration  of  a  clyster.  On  the  twelfth  the  milk 
receded,  and  the  pus  had  become  less  abundant,  and  of  firmer 
consistence.  On  the  sixteenth  day  there  was  not  above  an  inch 
of  tile  wound  open;  the  pus  was  healthy  and  moderate  in  quan- 
tity; and  the  patient  was  able  sit  up  a  little  in  bed.  On  the  22d 
she  was  allowed  to  leave  her  bed  for  a  short  interval;  but  her 
debility  was  very  great.  For  another  week  she  continued  to  im- 
prove; but  for  a  few  days  after  that,  in  consequence  of  her  having 
removed  to  an  uncomfortable  lodging,  and  being  restricted  to  an 
insufficient  diet,  the  wound  which  had  nearly  healed,  became  in- 
flamed, and  a  black,  foetid,  rough,  slimy  fluid,  was  discharged 
from  the  belly.  A  change  of  quarters  and  diet,  together  with 
the  use  of  chin  chona,  restored  her  former  favourable  state  of  pro- 
gress; and  on  the  forty-third  day  the  wound  was  completely 
closed.  Some  weeks  afterwards  the  surface  broke  out  again,  but 
in  no  long  time  it  was  finally  healed  up;  and  four  years  after  Dr- 
Miiller  saw  her  in  good  health,  which  she  said  had  not  suffered 
any  interruption  after  the  healing  of  the  wound.  The  child 
died  of  convulsions  when  three  months  and  a  few  days  old. 

■  1628.  In  fact,  we  may  safely  add,  that  in  almost  every  Jour- 
nal issued  of  late  upon  medicine,  we  find  instances  of  success  re- 
corded, of  both  the  Ca^sarean  operation  and  gastrotomy.  It  will 
be  seen,  even  from  the  imperfect  recital  made  of  the  cases  just 
related,  that  the  subjects  were  not  of  the  most  favourable  kind 
for  these  operations,  yet  they  were  followed  by  every  contem- 
plated success. 

1G29.  These  facts  should  be  duly  appreciated,  as  tlfty  are  of 
great  practical  value;  since  they  hold  out  strong  inducemenls  to 
imitation,  when  similar  necessities  present  themselves;  and  they 
ofier  resources,  by  which  lives  may  be  saved,  under  the  most 
disastrous  and  unpromising  circumstances.     They  moreover  dis- 


580  C-ESAREAN  OPERATION. 

tinctly  contradict,  the  unfavourable  reports  against  these  opera- 
tions, from  the  British  medical  writers  in  general,  and  of  Dr.  Os- 
born  in  particular.  For  were  it  true,  as  has  been  asserted  by  this 
gentleman,  that  the  woman  who  suffers  it,  "  is  doomed  to  inevita- 
ble destruction,"  it  should  be  proscribed  by  the  profession  with 
one  accord,  nor  should  it  ever  be  considered  as  a  resource  of  the 
art,  under  any  necessity,  however  imperious,  when  the  life  of  the 
woman  makes  a  part  of  the  calculation. 

1630.  But  on  the  other  hand;  if  it  be  satisfactorily  shown,  that 
the  success  attending  the  Cjesaraen  operation,  in  particular,  is  at 
least  equal  to  its  failures,  (and  of  which  we  think,  no  rational 
doubt  can  be  entertained,)  it  should  be  regarded  with  less  aver- 
sion, or  rather  viewed  with  equal  complacency,  with  several  other 
capital  operations,  in  which  necessity,  rather  than  very  frequent 
success,  is  pleaded  in  favour  of  their  performance. 

1631.  This  is  especially  necessary  under  certain  conformations 
of  the  pelvis — namely,  where  the  antero-posterior  diameter  of 
the  superior  strait,  is  less  than  two  inches  and  a  half.  In  such 
a  case,  we  are  persuaded,  that  delivery  by  the  crotchet  offers  an 
equal  risk  to  the  mother,  as  the  Csesarean  operation,  with  the  ab- 
solute destruction  of  the  child. 

1632.  The  Csesarean  sectionis  recommended  only  when  the 
child  cannot  be  delivered  without  the  mother  incurring  great  risk 
from  the  employment  of  J:he  crotchet — this  being  the  case  it 
should  be  well  and  satisfactorily  ascertained,  that  there  is  suffi- 
cient room  to  permit  the  base  of  the  child's  cranium  to  pass  with- 
out difficulty — I  have  already  stated,  (note  to  par.  1618,)  the 
space  I  think  absolutely  necessary  to  this  end;  therefore,  I  should 
not  think  it  justifiable  to  sacrifice  the  child  for  the  bare  possibility 
of  its  being  delivered  per  vias  naturales,  and  have,  if  it  fail,  no  al- 
ternative but  the  Csesarean  operation.  I  must  therefore  repeat, 
and  it  is  also  the  opinion,  1  am  happy  to  state,  of  Hull,  Hamilton, 
and  Johnstone,  that  Dr.  Osborn  has  fixed  his  limit  considerably 
too  low. 

Ifi33.  For  what  reprehension,  indeed  I  had  nearly  said  punish- 
ment, would  be  sufficiently  severe  for  that  practitioner,  who, 
after  havitig  destroyed  the  child,  should  find  it  impossible  to  de- 
liver it;  and  then,  for  its  accomplishment,  subject  the  poor  wo- 
man to  the  Cesarean  section?* 

*  This  must  not  be  looked  upon  as  a  gratuitous  position — for  the  case  has 


CESAREAN  OPERATION.  581 

1634.  Some  have  insisted,  that  this  operation  should  never  be 
performed  upon  the  living  woman,  let  the  exigency  of  the  case 
be  what  it  might — to  this  Dr.  Uenman  makes  the  following  judi- 
cious remarks:  "Impressed,  perhaps,  with  the  dread  of  the  ope- 
ration, they  did  not  distinguish  between  necessity  and  eligibility, 
and  therefore  wished  to  abolish  it  altogether,  which  would  be  an 
unnecessary  and  improper  general  rule.  But  if  it  were  to  be  per- 
formed only  when  the  patient  was  dead,  more  particularly  if  we 
were  to  wait  for  her  death,  as  the  only  proper  time  of  performing 
it,  it  would  be  fruitless.  For  I  do  not  find  any  instance  of  a  liv- 
ing child  extracted  by  this  operation  after  the  death  of  the  mother,* 
unless  the  child  escaped  by  the  same  stroke  as  that  which  proved 
fatal  to  tlie  mother,  of  which  the  accounts  seem  to  be  almost  fa- 
bulous, or  merely  accidental.  Yet,  as  in  cases  of  women  dying 
suddenly  in  convulsions,  haemorrhages,  rupture  of  the  uterus,  or 
other  rapid  diseases  or  accidents,  at  different  periods  of  pregnan- 
cy, or  of  a  labour,  it  is  possible  for  a  living  child  to  be  extracted 
after  the  death  of  the  mother,  by  speedily  performing  this  opera- 
tion; and  as  no  harm  can  possibly  result  from  the  operation,  sup- 
posing ourselves  disappointed,  no  reasonable  objection  can  be 
made  to  our  performing  it  under  such  circumstances."t 

1635.  I  might  ask,  what  degree  of  turpitude,  or  if  any,  should 
attach  when  a  woman  is  permitted  to  die,  knowing  she  must  die 
if  not  relieved,  if  the  only  alternative  in  such  case  be  neglected 
to  be  made  use  of,  however  hazardous?  What  is  it  that  renders 
this  operation  so  dangerous?  to  this  kind  of  query  Dr.  Denman 
remarks — 

1636.  "In  almost  every  case  in  which  this  operation  has  been 

occurred  more  than  once.  The  latest  instance  we  have  met  with  occurred  hi 
1823. 

*  There  are  two  instances,  within  a  few  years,  of  this  operation  being  per- 
formed after  the  death  of  the  mother  with  success  to  the  child.  One  of  these 
was  after  a  flooding-.  {Phil.  Med.  &  Phys.  Jour.  No.  II.  p.  189.)  The  other 
after  death  from  dysentarj'.  {Jour.  Univers.  des  Sciences  Med.  for  Oct.  1822.) 

f  I  have  been  twice  called  upon  to  perfoi-m  this  operation  after  the  death  of 
the  mother.  One  had  been  a  flooding-  case  ;  the  other  convulsions.  In  neither 
did  I  succeed ;  owing  probably  to  the  great  lapse  of  time  after  life  had  ceas- 
ed in  the  mother.  It  should,  notwithstanding,  always  be  attempted  under  such 
circumstances,  as  tlae  experiments  of  Dr.  Williams,  to  determine  the  exact  na- 
ture of  the  maternal  foetal  circulation,  prove,  tli.at  in  quadrupeds,  the  fatus  is 
found  alive  a  considerable  time  after  the  death  of  the  mother  ;  this  also  is  the 
case  most  probably  in  the  human  subject. 


582  CJESAREAN  OPERATION. 

performed  in  this  country,"  (Great  Britain,)  "the  patients  have 
died.  It  may  be  of  use  to  inquire  whether  their  deaths  were 
occasioned  by  any  disease  with  which  they  we-re  afflicted  be- 
fore the  time  of  labour;  were  the  consequence  of  the  state  to  which 
they  were  reduced  from  the  occurrences  of  labour,  before  the' op- 
eration was  performed;  or  were  the  inevitable  consequences  of 
the  operation.  In  cases  of  death  occasioned  by  wounds,  the  fol- 
lowing order,  in  which  the  danger  is  produced,  may  be  observed: 
first,  from  convulsions,  or  immediate  loss  of  blood ;  secondly,  from 
inflammation;  thirdly,  from  gangrene;  fourthly,  from  excessive, 
or  long-continued  suppuration,  under  which  the  patient  becomes 
hectic.  Though  almost  all  the  patients  on  whom  this  operation 
has  been  performed,  died,  their  death  happened  at  different  pe- 
riods; but  not  one  died,  either  while  the  operation  was  perform- 
ing, or  immediately  after  it.  No  convulsions  were  brought  on  by 
incisions;  nor  does  it  appear  that  any  of  them  sunk  through  the 
loss  of  blood  accompanying  or  succeeding  the  operation.  If 
we  may  judge  of  the  cause  of  death  by  the  time  of  the  patient's 
dying,  it  might  be  said  that  the  death  of  those  who  failed  within 
twenty-four  hours,  was,  probably,  owing  not  to  the  operation 
alone,  but  to  the  violence  of  this,  combined  with  that  of  the 
previous  disease;  but  when  ihey  survived  twenty-four  or  forty- 
eight  hours,  then  their  death  might  be  attributed  to  the  suc- 
ceeding inflammation,  in  a  body  predisposed  to  disease.  If  we 
had  the  liberty  of  selecting  a  patient  on  whom  to  try  the  merits 
of  this  operation,  we  certainly  should  not  choose  one  who  was 
either  very  much  distorted,  or  who  had  the  mollities  ossium, 
or  who  was  evidently  under  the  influence  of  some  dangerous 
disease,  or  who  had  been  several  days  in  labour;  because  the 
event  must  very  much  depend  upon  her  state  at  the  time  when 
the  operation  was  performed." — Introduction,  Francis's  ed. 
p.  424. 

1637.  Dr.  Denman  deprecates  the  conclusion,  that  he  is  at- 
tempting "  to  lessen  the  general  aversion  to  this  operation,"  and 
then  remarks,  "every  woman,  for  whom  the  Cesarean  operation 
can  be  proposed  to  be  pertormed,  will  probably  die;  and  should 
any  one  survive,  her  recovery  might  be  considered  as  an  escape, 
rather  than  a  recovery  to  be  expected,  though  there  is  always  a 
chance  of  saving  the  life  of  a  child.  But,  as  such  an  escape  may 
happen  in  any  case  in  which  the  operation  might  be  performed, 
we  may  and  ought  to  esteem  every  case  which  can  come  before 


CiESAREAN  OPERATION.  583 

US,  as  the  individual  case  in  which  a  happy  event  is  to  be  expect- 
ed. These  conclusions  will  lead  us  to  the  principle  of  necessity 
as  the  sole  justification  of  this  operation,  and  urge  us,  when  we  do 
perform  it,  and  as  far  as  may  be  in  our  power,  to  select  the  most 
eligible  time;  and  from  every  motive,  to  exert  all  our  judgment 
and  skill  for  the  service  of  the  patient,  as  if  we  were  certain  she 
would  survive."  p.  425. 

1638.  To  this  the  doctor  most  feelingly  and  properly  adds, 
**this  operation  can  seldom  be  required;  and  of  course  never  will 
be  performed  on  the  opinion  or  judgment  of  any  one  person,  un- 
less in  some  case  of  great  and  urgent  necessity;  and  a  concur- 
rence of  opinions  will  afford  the  best  security  against  its  being 
performed  unnecessarily;  and  if  it  were  to  be  presumed  by  a  sub- 
sequent measurement  of  the  pelvis,  and  a  new  consideration  of  all 
the  circumstances,  that  it  had  never  been  performed  without  such 
necessity ;  that  would  prove  only  that  the  operation  had  been 
abused,  and  not  serve  as  a  valid  argument  against  its  use  when 
such  necessity  really  existed."  p.  425. 

1G39.  It  iS  not  deformity  of  the  bones  of  the  pelvis  alone,  which 
may  give  rise  to  the  necessity  of  the  Csesarean  operation — this 
cavity  may  be  occupied  by  tumours,  or  exostoses,  so  as  to  prevent 
the  passage  of  the  child  at  full  time,  and  which  leaves  no  alter- 
native but  their  removal,  the  crotchet,  or  the  section  of  the  uterus. 
The  same  reasons  which  might  induce  us  to  have  recourse  to  the 
Csesarean  operation,  under  a  deformity  of  pelvis,  in  preference  to 
the  crotchet,  would  be  valid  in  ihis  state  of  the  pelvis;  namely, 
the  impracticability  of  labour  per  vias  naturales.  And,  with  re- 
spect to  the  removal  of  the  tumours,  it  may  be  impossible,  or  so 
hazardous  as  to  leave  the  choice  in  favour  of  the  Cesarean  opera- 
tion. See  a  valuable  Chapter  on  this  subject  by  Mr.  Burns,  Mid' 
wifery,  James's  ed.  p.  35. 


a.  Mode  of  performing  the  Cesarean  Operation. 

1640.  Having  never  performed  this  operation  on  the  living 
subject,  nor  ever  having  seen  it  performed,  I  must  rely  upon  the 
practice  and  experience  of  others,  for  the  manner  in  which  it 
should  be  done.  For  this  purpose  I  have  examined  with  care 
the  various  plans  proposed  for  this  operation;  and  think  that  the 
method  proposed  by  Baudelocque  unites  more  just  and  rational 
views  than  any  other  I  have  met  with.     I  shall  therefore  recom- 


584  CESAREAN  OPERATION. 

mend  it  to  be  followed,  should  a  necessity  present  itself  for  its 
adoption. 

1641.  He  says,  "  The  Cassarean  operation,  like  many  others, 
has  a  time  of  election,  and  one  of  necessity:  the  latter  always 
lakes  place  when  the  waters  are  evacuated,  except  as  circumstan- 
ces foreign  to  those  which  oblige  us  to  operate,  present  more 
urgent  indications."  This  necessity  is  also  created,  he  says,  by 
the  woman's  sudden  death,  and  the  rupture  of  the  uterus.  See 
Chapter  on  the  Rupture  of  the  Uterus. 

1642.  The  time  of  election  is,  he  thinks,  before  the  rupture  of 
the  membranes,  and  as  soon  as  the  labour  has  begun,  provided 
the  neck  of  the  uterus  is  effaced,  and  the  os  uteri  sufficiently 
open  to  transmit  the  lochia.*  By  operating  at  this  time,  agreea- 
bly to  M.  Levret,  the  extent  of  the  incisions,  both  of  the  abdo- 
minal and  uterine  parietes,  will  be  less  after  the  child  is  deliver- 
ed. For  it  is  very  certain  that  an  incision  of  six  inches  will 
affect  a  smaller  number  of  fibres  and  vessels,  when  the  uterus  is 
still  distended  with  the  waters,  than  when  it  is  strongly  contract- 
ed on  the  child's  body,  and  reduced  a  fifteenth  or  a  twelfth  part 
of  its  size. 

1643.  He  recommends  two  bistouries  to  be  employed:  one 
straight  and  probe-pointed,  and  one  curved;  but  this  last  is  not 
necessary;  the  common  scalpel  is  better  than  the  curved  bistoury 
— there  must  be  at  hand  needles,  ligatures,  compresses,  lint,  fine 
linen,  brandy,  &c.  The  woman  must  be  placed  on  a  pretty  nar- 
row bed,  of  sufficient  height,  and  the  bed  should  be  the  one  on 
which  she  is  finally  to  lie,  that  she  need  not  be  disturbed  after 
the  operation.  The  bed  should  be  so  protected,  as  to  prevent  its 
being  wetted  by  the  discharges,  and  when  the  cloths  are  with- 
dravvn,  to  leave  the  woman  dry.  She  should  be  laid  upon  her 
back,  with  the  legs  and  thighs  extended  while  the  incision  is 
made;  and  half  bent,  during  the  extraction  of  the  child. 

1644.  He  recommends,  as  do  all  the  best  writers  upon  the  sub- 
ject, that  the  incision  be  made  in  the  linea  alba:  when  the  part 
of  the  abdomen  is  determined  on,  the  urine  drawn  off,  and  the 
woman  properly  placed,  the  abdominal  teguments  should  be  care- 
fully cut  through,  till  the  aponeuroses  which  form  the  linea  alba 

*  In  Germany,  the  time  chosen  for  tJie  operation  is  similar  to  that  recom- 
mended by  Baudelocque;  that  is,  when  tlie  mouth  of  the  uterus  is  opened,  and 
before  the  waters  are  discharged. 


CESAREAN  OPEUATION.  585 

are  perceived.     The  linca  alba*  must  now  be  cautiously  divided, 
to  discover  the  peritoneum,  in  which  a  small   opening  must  be 

•  It  seems  from  the  researches  of  Dr.  Mansfield  Into  the  antiquity  of  this  op- 
eration, that  it  is  much  older  than  has  been  admitted  by  Osiander,  Kurt  Spran- 
gel,  and  some  others.  For  he  informs  us,  that  in  the  TJudmud,  one  of  the  old- 
est works  among  the  Jews,  and  the  product  of  the  most  learned  among  that 
people  at  that  time,  this  operation  is  not  merely  indicated,  but  distinctly  men- 
tioned in  the  following  words:  "In  a  case  of  twins,  neither  the  first  cliild 
which  shall  be  brought  into  the  world  by  cutting  into  the  abdomen,  nor  the  se- 
cond can  receive  the  rights  of  primogeniture,  either,  as  regards  the  office  of 
priest  or  the  succession  of  property." 

The  indications  for  this  operation  are  not  pointed  out.  Again,  in  a  work 
called  the  Nidda,  which  is  looked  upon  as  an  appendix  to  the  Thalmud,  it  is 
stated  in  allusion  to  the  time  the  husband  must  abstain  from  their  wives  after 
delivery,  "that  it  is  not  necessary  for  the  woman  to  observe  the  days  of  purifi- 
cation after  the  removal  of  the  child  through  the  parietes  of  the  abdomen." 

The  conclusion  is  irresistible,  that  the  Cesarean  operation  was  known  at 
that  time;  and  that  it  was  frecjiiently  performed  upon  the  living  svibject ;  and 
more  especially,  as  there  are  several  controversies  respecting  the  necessity  for 
women  who  have  suffered  this  operation,  to  observe  the  days  of  purification. 

The  same  authority  also  proves,  that  the  cutting  into  the  linea  alba  is  not  the 
oldest  mode  of  performing  this  operation,  as  supposed  by  Osiander ;  but  that 
operating  in  the  side  claims  the  priority,  as  Maimonides,  who  wrote  a  commen- 
tary on  the  Nidda,  declares  certain  words  to  mean,  "that  a  woman,  who  can- 
not bear  a  cliild  in  the  natural  way,  shall  be  opened  in  the  side,  and  in  this  way 
delivered  of  her  offspring." 

The  mode  of  performing  this  operation,  is  in  the  wordsof  Salomo  Jarhi,  one 
of  the  learned  commentators  upon  the  Nidda;  "the  abdomen,"  he  says,  "must 
be  opened  by  Samm,  the  child  extracted,  and  the  parts  healed."  Samm  in  this 
passage  is  said  to  signify  an  instrument,  which  was  sufficiently  sharp  for  the 
division  of  various  parts. 

It  seems  that  with  the  ancients,  the  operation  was  always  performed  on  the 
side;  and  the  left  was  first  chosen  on  account  of  the  liver ;  but  afterwards  it 
was  performed  on  either  side,  as  an  opinion  may  have  been  entertained  of  the 
situation  of  tlie  placenta.  The  incision  was  made  on  the  external  side  of  the 
recti  muscles,  and  parallel  to  them;  frequently  It  was  carried  in  an  oblique  di- 
rection towards  the  pul)es.  The  bleeding  which  attended  this  mode  of  per. 
forming  tlie  operation  must  necessarily  have  been  very  considerable,  from  the 
frequent  wounding  of  the  epigastric  artery;  but  yet  itisaremarkablefact,  that 
from  1500  to  1769,  a  space  in  which  according  to  Stein,  eighty-two  Caesarean 
operations  were  performed  in  this  mode,  only  six  turned  out  unfortunate. 

About  the  year  1770,  some  celebrated  accoucheurs  of  Germany  and  France 
began  to  adopt  the  linea  alba  as  the  best  sjjot  for  the  incision.  Deleurge  was 
ilie  chief  person  who  showed  the  advantages  which  were  to  be  derived  from 
this  mode  of  performing  the  operation,  by  preventing  the  protrusion  of  the  in- 
testines, and  the  loss  of  blood.  Since  this  time  the  linea  alba  is  the  spot  gene- 
rally chosen. 

Lauverjat  soon  after  recommended,  that  the  incision  should  be  made  trans- 
74 


586  CESAREAN  OPERATION. 

made.  A  finger  of  the  left  hand  must  be  introduced  into  this 
hole,  and  the  abdominal  teguments  a  little  raised  by  it  to  prevent 
any  of  the  parts  within  getting  injured  by  the  instrument,  for  which 
this  finger  serves  as  a  director, 

1645.  The  first  incision  must  extend  from  the  umbilicus  to 
within  an  inch,  or  an  inch  and  a  half  at  most,  of  the  symphysis 
of  the  pubes.  This  he  says  is  a  little  longer  than  it  is  usually 
made,  but  the  uterus  is  better  discovered  by  it,  and  it  can  in  con- 
sequence be  opened  nearer  to  the  fundus.  He  thinks  the  perito- 
neum is  better  opened  from  above  downwards,  taking  care  to  go 
along  one  of  the  sides  of  the  bladder,  when  this  organ  rises  up  too 
high,  as  sometimes  happens. 

1646.  The  uterus  should  be  fixed  by  the  hands  of  an  assistant, 
by  pressing  a  little  on  the  sides,  and  another  make  a  similar  pres- 
sure above  the  umbilicus  in  order  to  circumscribe  the  uterine  tu- 
mour, and  hinder  the  intestines  from  presenting  at  the  wound. 

1647.  Professor  Graafe  believes  he  has  diminished  the  dangers 
of  this  operation  by  the  manner  in  which  he  conducts  it,  of  which 
the  following  is  a  summary: — The  operation  should  be  performed 
if  possible,  at  the  full  period  of  utero-gestation,  and  at  the  time 
labour  has  commenced;  the  incision  should  be  made  through  the 
linea  alba,  below  the  umbilicus,  and  should  extend  five  inches; 
the  incision  into  the  uterus  should  be  four  inches  six  lines  in 

versely;  he  performed  the  operation  in  this  manner  twice  with  success.  He 
proposes  to  make  the  first  incision  between  the  recti  muscles  and  the  spine, 
just  below  tlie  third  false  rib,  at  the  point  towards  which  the  uterus  projects: 
other  modes  have  also  been  suggested. 

It  is  however  agreed,  by  all  the  best  continental  accoucheurs  that  neither  of 
the  modes  proposed  is  applicable  in  eveiy  case,  owing  to  the  structure  of  the 
integuments,  the  situation,  form,  and  projection  of  the  uterus.  If  structure  only 
be  regarded,  the  linea  alba  presents  the  greatest  advantages.  But  advantageous 
as  it  is.  Dr.  Schenk  thinks,  it  cannot  always  be  chosen.  And  the  rule  now  on 
the  continent  is,  to  cut  opposite  to  that  part  where  the  projection  of  the  uterus 
is  the  greatest. 

The  reasons  assigned  for  tins  are,  that  the  integuments  of  the  abdomen  lay 
closer  to  the  gravid  utenis,  whilst  the  omentum  and  the  intestines  are  pressed 
either  above,  or  to  one  side,  so  that  an  assistant  can  very  readily  prevent  tliem 
from  protruding  in  the  way  of  tlie  operator. 

In  England  the  linea  alba  is  generally  chosen  for  the  performance  of  this 
operation;  and  it  appears  to  be  the  best,  as  less  hsmorrhage  follows,  and  there 
is  a  greater  facility  of  producing  adhesion  here  than  in  other  parts.  With  good 
assistance  it  is  thought,  protrusion  may  alwa}  s  be  prevented,  by  employing  large 
sponges  instead  of  the  hands. — Edln.  Med.  and  Surg.  Journ.  No.  IX,  of  New 
Scries. 


CESAREAN  OPERATION.  587 

length.  To  prevent  the  escape  of  the  intestines  through  the  ex- 
ternal incision  or  wound,  Dr.  G.  advises  the  employment  of  large 
pieces  of  sponge,  prepared  with  wax,  each  one  foot  long,  six  in- 
ches broad,  and  nearly  three  inches  thick.  Three  such  pieces 
are  necessary  for  one  operation.  They  should  be  applied  to  the 
abdomen,  so  as  to  leave  for  the  incision,  a  space  eight  inches  long, 
by  three  or  four  wide,  and  are  to  be  retained  by  two  or  three  as- 
sistants, who  should  make  moderate  pressure  with  the  hand;  care 
being  previously  taken,  that  every  portion  of  intestine  has  been 
removed  from  the  place  reserved  for  the  incisions.  Pressure  on 
the  sponge  will  then  keep  the  bowels  at  a  distance,  and  prevent 
their  escape.  If  the  placenta  be  not  completely  detached,  it 
should  be  removed  by  the  surgeon,  in  preference  to  its  remain- 
ing in  the  uterus.  The  edges  of  the  wound  in  the  abdomen, 
should  be  kept  in  contact  by  sutures  made  with  very  soft  ribands, 
eighteen  lines  in  width,  and  with  flat  needles  with  two  cutting 
edges.  Three  sutures,  thus  effected,  are  as  advantageous  as  six 
others  with  a  simple  thread.  Farther  to  secure  the  lips  of  the 
wound,  four  or  five  adhesive  straps  are  necessary;  each  eighteen 
lines  in  breadth,  and  long  enough  to  pass  once  and  a  half  round 
the  abdomen;  the  middle  being  applied  to  the  back,  and  the  ex- 
tremities crossing  in  front,  above,  below,  and  between  the  su- 
tures. After  the  operation  the  mother  demands  rest,  and  seda- 
tives, as  laurel  water,  extract  of  henbane,  or  the  infusion  of  bel- 
ladonna, to  be  administered  as  enemata.  When  inflammation 
ensues,  the  loss  of  blood  is  the  best  remedy;  salts  and  calomel  do 
not  answer.  If  nervous  symptoms  arise,  opium,  with  the  aethers, 
in  small  and  repeated  doses  are  useful,  while  attention  is  to  be 
paid  to  the  lochial  discharge,  and  the  mammary  secretion.  In 
the  management  of  the  wound,  the  sutures,  and  the  kind  of  sup- 
puration demand  attention,  especially  at  the  inferior  portion  of 
the  wound.  The  adhesive  plasters  ought  to  be  continued  for  a 
long  time.* 

1648.  The  abdomen  being  opened  to  a  convenient  extent,  a 
little  stronger  pressure  is  to  be  made  above  the  umbilicus,  to  bring 
the  fundus  of  the  uterus  nearer  to  the  superior  angle  of  the 
wound;  it  is  then  to  be  opened  in  the  middle  of  its  anterior  part 
with  the  scalpel,  until  the  membi'anes  are  discovered.  An  open- 
ing, only  large  enough  to  admit  the  finger,  should  be  made  into 

*  The  North  American  Med.  aiul  Siir.  Jour.  No.  IX. 


588  c;esarean  operation. 

them,  takinj^  care  not  to  wound  the  child;  the  forefinger  is  then 
to  be  passed  into  their  cavit}^  as  a  conductor  for  the  bistoury, 
with  which  the  uterus  must  be  opened,  cutting  from  within  out- 
wards, as  was  done  with  the  teguments  of  the  abdomen. 

1649.  This  incision  in  the  uterus  must  be  extended  at  least  as 
high  as  the  superior  angle  of  the  external  wound,  terminating 
it  below,  an  inch  and  a  half,  or  thereabouts,  above  the  inferior 
angle  of  it.  The  extent  of  this  incision  must  be  determined  in 
some  measure  by  the  size  of  the  child,  which  is  supposed  in  ge- 
neral to  be  such,  as  will  in  its  small  circumference  measure  ten, 
or  ten  and  a  half  inches.  An  opening  then,  of  five  or  six  inches, 
is  generally  sufficient;  but  it  is  belter  to  make  it  larger  than 
smaller,  to  avoid  tearing  the  angles  of  the  wound,  when  the  child 
passes  it. 

1650.  Should  the  centre  of  the  placenta  present  itself  under 
the  knife,  it  must  be  cut;  but  if  the  edge  is  found  in  the  neigh- 
bourhood of  the  wound,  it  is  better  to  detach  it  in  order  to  open 
the  membranes. 

1651.  When  the  uterus  is  properly  opened,  the  hand  must  be 
passed  into  it,  and  the  feet  searched  for  and  brought  out — pro- 
ceeding as  if  a  child  were  to  be  delivered  footling.  This  rule 
must  be  observed,  except  where  the  head  presents  naturally  to 
the  wound  of  the  uterus;  if  it  be  not  expelled  speedily  by  the 
natural  contractions  of  the  uterus,  its  exit  may  be  favoured,  by  a 
slight  pressure  upon  the  sides  of  the  belly  of  the  woman,  and  at 
some  distance  from  the  incision,  or  by  insinuating  the  forefinger 
of  eacli  hand,  under  the  angles  of  the  lower  jaw. 

1652.  The  placenta  is  soon  expelled  by  the  natural  powers  of 
the  uterus  forcing  it  towards  the  wound;  this  may  be  favoured 
by  gently  acting  upon  the  cord,  or  by  taking  hold  of  the  edge  of 
the  placenta  with  the  fingers,  so  soon  as  it  may  present  itself. 
Care  should  be  taken  to  remove  any  coagula  that  may  have  form- 
ed within  the  uterus,  and  a  finger  passed  through  its  neck,  to 
force  anything  that  may  have  formed  in  it  into  the  vagina.  If  the 
uterus  remain  soft  and  inactive  after  the  removal  of  the  placenta,  • 
it  must  be  gently  stimulated  externally  by  the  fingers,  to  oblige 
it  to  contract. 

1653.  But  little  blood  is  lost  when  the  uterus  is  cut  in  the  cen- 
tre of  its  anterior  face,  unless  the  placenta  be  attached  there,  and 
even  then  the  discharufe  is  but  of  short  continuance,  if  this  organ 


CESAREAN  OPERATION.  589 

contract  forcibly.  A  bleeding  may  supervene  some  hours,  or 
even  days,  after  the  operation — by  exciting,  however,  the  tonic 
contraction  of  the  uterus,  it  will  be  put  a  stop  to. 


b.  Treatment  after  the  Operation. 

1654.  The  general  indications  presented  after  the  operation, 
consist;  first,  in  the  discharge  of  any  foreign  matter  from  tlie 
abdomen,  which  may  have  passed  into  it  during  the  operation; 
this  should  be  attempted  before  the  wound  is  dressed,  either  by 
placing  the  woman  in  a  convenient  situation,  or  by  pressure  ap- 
plied to  the  sides  above  the  hips.  Sometimes  warm  water  has 
been  injected  for  this  purpose. 

1655.  The  second,  is  the  dressing  of  the  wounds,  &c. — Hie 
wound  in  the  uterus  will  require  but  little  attention;  since,  if 
this  organ  preserve  its  powers,  its  contraction  will  lessen  it  one 
half,  immediately  after  the  operation,  and  would  quickly  heal, 
were  it  not  for  the  passage  of  the  discharges,  which  the  uterus 
furnishes  so  abundantly  the  first  few  days  after  delivery. 

1656.  The  third,  consists  in  preventing  or  overcoming  inflam- 
mation; this  must  be  attempted  by  a  strict  antiphlogistic  regi- 
men, confining  the  patient  to  barley-water,  thin  gruel,  tapioca, 
rennet  whey,  &c. — forbidding,  in  the  most  earnest  manner,  all 
stimulating  drinks,  meat,  broths,  &c. ;  in  a  word  everything 
animal,  or  spirituous,  unless  some  contraindications  may  exist, 
or  arise;  in  such  case,  the  patient  must  be  treated  agreeably  to 
the  judgment  of  the  practitioner. 

1657.  It  is  thought  by  some,  that  in  dressing  the  external 
wound,  sutures  are  not  absolutely  necessary ;  but  surgeons  of  the 
highest  chai'acter  think  it  far  the  best  method  for  securing  the 
firmest  and  most  solid  cicatrix.  Adhesive  strips  will  bring  the 
parts  very  well  together,  but  the  flaccidity  of  the  abdominal  pa- 
rietes  prevents  the  exact  coaptation  that  is  essential  to  a  firm 
union.   See  par.  1647,  &c. 

1658.  It  is  admitted  that  sutures  have  their  disadvantages,  as 
they  are  sometimes  obliged  to  be  cut,  or  at  least  to  be  loosened, 
owing  to  the  distention  of  the  abdomen,  or  to  give  transit  to  co- 
agula.  The  quilled  suture  is  thought  by  some  to  be  the  best;  but 
whichever  is  employed,  care  should  be  taken  not  to  wound  the 
peritoneum  in  their  formation.     Sutures  are  to  be  so  arranged  as 


590  CESAREAN  OPERATION. 

to  permit  the  discharge  of  fluids  from  the  wound;  they  are,  there- 
fore, not  to  be  unnecessarily  multiplied. 

1659.  This  wound  is  thought  to  require  more  frequent  dressing? 
than  any  other  penetrating  the  abdomen,  in  order  to  prevent 
extravasations,  and  the  formation  of  clots,  which  the  bandage  re- 
tains within  the  lips  of  the  wounds;  the  dressings  must  be  re- 
moved daily,  or  even  oftener  if  there  be  reason  to  suspect  either 
protrusions  of  the  intestines,  omentum,  or  extravasations.  The  fre. 
quency  of  dressing,  however,  will  be  diminished,  as  the  lochia 
may  flow  more  abundantly  through  the  natural  passages.  The 
dressings,  agreeably  to  Baudelocque,  should  be  very  simple,  and 
without  ointment. 

1660.  It  evidently  appears,  that  there  is  much  advantage  in 
keeping  up  a  free  discharge  of  the  lochia,  through  the  os  uteri; 
and  for  this  purpose  several  schemes  have  been  proposed,  such  as 
a  canula,  or  hollow  pessary,  &c.  I  do  not  think  this  can  be 
either  an  easy  or  a  useful  plan,  and  that  the  end  could  be  much 
better  answered  by  the  occasional  introduction  of  a  very  large- 
sized  bougie;  this,  I  am  disposed  to  believe,  would  not  be  at- 
tended with  much  difficulty — but  I  confess  its  recommendation  is 
speculative. 

1661.  It  appears,  however,  to  me  evident,  that  some  such  con- 
trivance is  practicable,  and  may  be  well  worthy  the  attention  of 
one  who  may  be  under  the  dreadful  necessity  of  performing  this 
operation;  especially,  as  Baudelocque  declares  it  to  be  his  opi- 
nion, that  clearing  the  neck  of  the  uterus  from  time  to  time? 
would  render  the  Csesarean  operation  more  certain.  And  in  an 
operation  of  such  magnitude  and  consequence,  attention  should 
be  paid  to  the  smallest  circumstance,  if  it  contribute  to  render  it 
less  fatal. 

1662.  I  have  directed  the  patient  to  be  restricted  to  the  most 
rigid  antiphlogistic  treatment,  (1656,)  wherever  there  may  be  in- 
flammation, or  even  a  tendency  to  it;  I  repeat  it  here,  that  I  may 
say,  that  with  the  same  object  in  view,  Baudelocque  recommends 
the  same  plan;  but  he  unfortunately,  in  his  enumeration  of  the 
antiphlogistic  articles,  reckons  veal  and  chicken  broth,  both,  or 
either  of  which,  I  would  most  positively  forbid.  He  also  recom- 
mends, that  the  patient  should  suckle  her  child  if  it  be  living;  if 
not,  to  have  the  breast  drawn  by  glasses  or  puppies. 

1633.  Baudelocque  farther  says,  "  that  after  the  perfect  conso- 


CESAREAN  OPERATION.  591 

lidation  of  the  wound,  the  woman  should  never  go  without  a  pro- 
per bandage,   to  prevent  a  subsequent  hernia."* 

*  Since  writing  the  above,  I  received  the  following  letter  from  my  friend, 
Dr.  W.  E.  Horner,  Adjunct  Professor  of  Anatomy  in  the  University  of  Penn- 
sylvania. The  importance  of  its  contents  will  amply  apologize  for  its  introduc- 
tion : — 

My  dear  sia: — The  Csesarean  operation,  as  commonly  performed,  puts  into 
such  danger  the  life  of  the  mother,  that  it  is  still  a  desideratum  to  ascertain  some 
modification  of  it,  which  may  diminish  its  fatality,  and  thereby  inspire  the  pro- 
fession with  more  confidence  and  promptness  in  undertaking  it.  Several  changes 
in  it  have  been  proposed  from  the  time  of  its  first  adoption,  principally  with  a  view 
to  avoid  the  chances  of  wounding  the  urinary  bladder,  or  of  catting  through 
the  large  vessels,  which,  in  a  state  of  pregnancy,  occupy  the  broad  ligaments 
of  the  uterus.  In  their  principle  they  differ  materially  from  each  other,  as  they 
all  involve  the  necessity  of  cutting  into  the  cavity  of  the  peritoneum,  on  wliich 
circumstances,  it  is  generally  conceded,  the  gi-eat  danger  of  the  operation 
depends. 

This  operation  has  been  a  frequent  subject  of  conversations  which  I  have  held 
with  our  common  friend.  Dr.  Physick,  and  I  have  been  as  often  instructed  by 
the  views  which  he  has  taken  of  it.  More  than  two  years  ago,  it  being  then  a 
matter  of  particular  inquiry  with  me,  1  was  struck  by  the  following  proposition 
of  his  in  regard  to  it,  which  made  a  very  strong  impression  on  me,  and  the  just- 
ness of  which  I  have  ever  since  been  extremely  anxious  to  verify  by  dissection. 
It  is  well  known  to  anatomists,  that  but  a  very  small  portion  of  the  upper  anteri- 
or pai-t  of  the  vagina,  in  the  unimpregnated  state  is  covered  by  peritoneum,  and 
that  the  portion  of  peritoneum  which  lies  upon  the  fore  part  of  the  cervex  uteii 
and  vagina  is  connected  to  them  by  a  long,  loose,  cellular  tissue,  which  .allows 
the  peritoneum,  in  the  distensions  of  the  urinary  bladdei-,  to  be  separated  still 
farther  up  from  the  vagina. 

It  has  not  been  equally  remarked,  that  this  peritoneal  covering  of  the  vagina 
is  of  very  fugitive  character,  and  that  in  the  moderate  distentions  of  the  blad- 
der, the  peritoneum  leaves  completely  the  vagina,  and  apphes  itself  to  the  blad- 
der. It  is  also  true,  that  if  the  distention  of  the  bladder  be  much  increased,  the 
peritoneum  even  leaves  the  anterior  face  of  the  cervix  uteri,  and  its  reflexion 
to  the  bladder  departs  thence  at  the  lower  part  of  the  body  itself  of  the  uterus. 
By  a  fortunate  coincidence,  I  have  at  this  moment  under  my  observation, 
these  parts  about  the  end  of  the  sixth  month  of  pregnancy;  the  fatus  having 
been  just  expelled  from  the  uterus,  with  its  head  still  remaining  in  the  vagina, 
owing  to  a  breech  presentation.  It  may  be  mentioned  in  passing,  that  there  is 
good  reason  to  believe  that  tlie  uterus  here  took  on  the  parturient  action,  after 
the  other  phenomena  of  life  had  ceased.  In  this  case  I  find  the  peritoneum 
drawn  off  from  the  vagina  by  a  common  distention  of  the  bladder.  And  by  my 
drawing  moderately  ut  the  bladder,  the  peritoneum  leaves  the  cervex  uteri 
after  the  same  manner  that  it  does  in  the  unimpregnated  state. 

Dr.  Physick,  founding  his  Ideas  upon  a  similar  observation  made  in  early  life, 
during  the  dissection  of  a  pregnant  woman,  proposes,  that  in  the  Cesarean  ope- 
ration, a  horizontal  section  be  made  of  the  parietes  of  the  abdomen,  just  above 
the  pubes.     That  the  peritoneum  be  stripped  from  the  upper  fundus  of  the 


592  ON  PREMATUKE  DELIVERY. 


Sect.  V. — e.  On  Py'emaiure  Delivi 


ry. 


1664,  About  the  year  1756,  as  Dr.  Denman  informs  us  on  the 
authority  of  Dr.  Kelly,  there  was  a  consultation  of  the  most  emi- 
nent men  at  that  time  in  London,  upon  the  morahty  and  advan- 
tages which  might  result  from  inducing  premature  labour,  in 
cases  of  deformity  of  the  pelvis.  The  first  case  which  was  judged 
proper  for  the  trial  fell  under  the  care  of  Dr.  M'Cauley,  and  ter- 
iDinated  successfully.  Since  this  time,  it  has  been  so  frequently 
repeated  in  England  and  elsewhere,  as  to  satisfactorily  establish 
its  "  morality,"  "safety,"  and  "  utility."  This  being  the  case,  I 
shall  not  enter  into  its  defence,  as  its  frequent  success  places  it 
above  such  a  necessity;  but  take  its  propriety  for  granted,  and 
merely  lay  down  such  rules  for  its  performance,  as  have  been 
found  from  experience  best,  together  with  a  few  remarks  upon 
these  rules,  en  passant. 

Velpeau  speaks  both  disparagingly,  and  inconsistently  of  this 
operation.  He  first  informs  us,  that  the  view  his  brethren  in 
France  have  taken  of  this  operation,  renders  it  criminal — for  it 
is  dogmatically  assumed,  that  no  one  has  a  right  to  destroy  a 
foetus  at  any  period  of  utero-gestation  even  (as  we  suppose)  to 

bladder,  by  dissecting  through  the  connecting  cellular  substance,  which  will 
bring  the  operation  to  that  portion  of  the  cervix  uteri  where  the  peritoneum 
goes  to  the  bladder.  The  incision  being  continued  through  this  portion  of  the 
uterus,  will  open  its  cavity  with  sufficient  freedom  for  the  extraction  of  the 
foetus.  All  of  which  the  Doctor  supposes  may  be  done  by  a  carefiJ  operation, 
without  cutting  through  the  peritoneum. 

It  is  evident,  that  if  this  be  a  practicable  operation,  it  will  diminisli  immensely 
the  tendency  to  peritoneal  inflammation,  and  will  in  fact,  put  it  on  a  foundation 
of  danger  very  closely  allied  to  the  taking  up  of  the  external  iliac  artery,  near 
its  origin,  by  turning  aside  the  peritoneum;  an  operation,  the  success  of  which 
is  sufficient  to  justify  any  competent  person  in  undertaking  it.* 

Knowing  the  value  which  you,  as  well  as  myself,  put  upon  the  suggestions 
of  a  person  whose  mind  is  so  i-emarkable  for  its  professional  sagacity  and  re- 
sources, 1  have  thought  that  even  a  proposition  not  yet  confirmed  by  actual  expe- 
rience of  its  success,  would  not  be  an  unacceptable  addition  to  the  fund  of  in- 
formation you  are  about  to  communicate  to  the  public. 
I  remain,  very  sincerely,  your  friend, 

W.  E.  HORNER. 

To  Doctor  Dewees.  Sept.  28,  1824- 

*  Dr.  Phydck  proposes  that  the  operation  be  performed  wit\a  modei'oiely  dis- 
tended bladder,  and  that  a  catheter  should  be  introduced  previously,  to  ascertain  its 
situation. 


ON  PREMATURE  DELIVEKV.  593 

protect  the  mother's  life  against  the  dangerous  resources  of  the 
Sigaultian  operation,  the  Cssarean  operation,  ernbryulcia,  or  the 
chance  of  dying  undelivered.  For  these  are  the  only  chances  a 
woman  can  have,  who  has  a  pelvis  so  deformed  as  to  render  pre- 
mature delivery  eligible. 

He,  however,  appears  immediately  after  to  dissent  from  such  a 
conclusion,  and  observes,  <' As  regards  myself,  I  avow,  I  cannot 
put  in  comparison  the  precious  life  of  a  foetus  of  three,  four,  five, 
or  six  months,  a  being  scarcely  differing  from  a  plant,  one  that 
is  bound  by  no  ties  to  the  external  world,  with  that  of  the  adult 
woman,  whom  a  thousand  social  relations,  interest  us  to  save: 
therefore,  in  a  case  of  extreme  narrowness  of  the  pelvis,  and  where 
it  was  mathematically  demonstrated,  that  delivery  at  the  full  pe- 
riod was  impossible,  I  would  not  hesitate  to  recommend  produc- 
ing abortion,  in  the  first  months  of  gestation."  In  this  sentence 
we  discover  a  disposition  to  aid  the  woman  by  destroying  the 
ovum  in  the  early  months  of  gestation.  For  what  purpose  is 
feeling  exercised  towards  the  woman  but  to  prevent  the  use  of 
the  terrible  resources  of  art  under  such  circumstances  at  full  time, 
and  thus  to  save  her  life — so  far,  well — but  Mr.  V.  immediately 
adds:  "Eut  it  is  altogether  anotlier  thing,  when  there  shall  be 
two  inches  and  a  half  at  least  between  the  pubis  and  the  sacrum: 
as  it  has  happened  that  the  ovum  has  been  expelled  spontaneously, 
and  the  foetus  born  alive,  therefore,  the  honour  of  art  and  of  hu- 
manity unite  in  forbidding  the  use  of  any  instrument,  or  any  other 
attempt  that  might  destroy  the  foetus." 

We  would  ask,  what  proportion  exists,  of  such  escapes,  to  the 
victims,  that  such  a  recommendation  of  delay,  would  have  .''  there 
would  be  at  least  a  hundred  to  one,  against  the  child  being  de- 
livered by  the  natural  agents  either  dead  or  alive,  and  the  wo- 
man escape  from  either  of  the  terrible  resources  for  impractica- 
ble labour;  as  the  Csesarean,  or  Sigaultian  operations,  or  cephalo- 
tomy. 

He  also  declares,  that  "delivery,  when  induced  previously  to 
the  seventh  month  will  necessarily  kill;  and  it  rarely  fails  to 
cause  the  death  of  the  foetus,  at  the  seventh  or  eighth."  Now 
this  is  evidently  assuming,  that  which  remains  to  be  proved — 
namely,  that  the  death  of  the  foetus  is  inevitable;  for  we  are 
thoroughly  convinced,  that  children  have  lived,  that  were  spon- 
taneously delivered,  even  as  early  as,  or  very  little  beyond 
75 


594  ON  PREMATURE  DELIVERY. 

the  sixth  month;  and  as  this  operation  offers  a  much  better  chance 
to  the  mother  at  either  of  these  periods,  even  than  embryulcia, 
which  is  generally  considered  the  safest  of  these  operations,  it 
should  be  preferred,  were  the  chances  even  fewer,  in  favour  of 
the  child.  But,  at  present,  it  is  a  matter  of  history,  that  the 
operation  succeeds;  and  this  with  very  little  danger  to  the 
mother;  therefore,  it  is  to  be  preferred  in  all  such  cases  of  defor- 
mity as  forbid  the  expectation  or  chance,  of  the  child  being  born 
alive,  by  the  natural  powers. 

In  another  sentence,  Mr.  V.  asks  the  following  extraordinary 
question — "Kit  must  be  destroyed,  (the  child,)  why  not  wait  to 
the  full  period  ?  by  doing  so,  we  shall  not  destr.oy  the  few  chances 
we  have,  of  seeing  a  favourable  termination  of  the  labour."  We 
are  led  to  infer  from  this  question,  that  Mr.  V.  thinks  there  is 
less  danger  from  embryulcia  at  the  full  period  of  utero-gestation, 
in  cases,  where  the  embryo  (agreeably  to  his  phraseology,)  must 
be  destroyed,  than  even  at  an  early  period  of  pregnancy;  a  cir- 
cumstance, in  which  he  will  not,  we  think,  be  borne  out  by  any 
other  practitioner — and  for  these  especial  reasons.  First,  if  pre- 
mature delivery  be  induced  even  after  the  sixth,  or  a  little  before 
the  seventh  month,  the  \:\\\\il  must  not,  nur  does  not,  necessarily 
perish.  Secondly,  that  after  the  seventh,  and  from  that  to  the 
eighth  month,  the  chance  for  the  child  is  increased,  provided, 
the  diameters  of  the  pelvis,  has  justified  so  long  a  delay.  Thirdly, 
because,  if  the  case  require  the  puncture  of  the  ovum,  it  would 
be  folly  to  wait  to  the  term  of  labour,  in  expectation  of  any  one 
chance  "of  a  favourable  termination  of  the  labour,"  since,  the 
size  of  the  child's  head,  if  alive,  and  this  is  taken  for  granted, 
must  necessarily  increase  the  longer  it  remains  in  the  uterus — for 
we  may  well  ask  in  turn,  how  the  chances  for  "a  favourable  ter- 
mination" are  increased,  by  a  delay  that  will  increase  the  evil, 
that  renders  the  induction  of  premature  delivery  necessary; 
namely,  an  increase  of  disparity  between  the  size  of  the  child's 
head,  and  the  pelvis!  Is  this  condition  not  admitted,  (namely, 
that  the  head  continues  to  augment  in  size,)  when  he  says,  "  If 
with  a  view  of  greater  security  (of  the  preservation  of  the  child) 
the  operation  be  deferred  a  fortnight  more,  what  assurance  can 
we  have,  that  the  head  is  not  too  large  already,  to  pass  through 
the  straits  ?  Traite  Elementaire  de  I'art  des  Accouchemens. 
Tom.  11.  p.  807,  &c. 

1665.   Dr.  Merriman  has  summed  up  within  a  very   short 


ON  PREMATURE  DELIVERY.  595 

space  the  laws  which  should  govern  in  this  case,   which  I  shall 
introduce,  with  a  few  remarks. 

1666.  "I.  A?  the  primary  object  is  to  preserve  the  life  of  the 
child,  the  operation  should  never  he  performed  till  seven  com- 
plete 7nonths  of  utero-gestation  have  elapsed;  and,  if  the  pelvis 
of  the  mother  be  not  too  much  contracted  to  allow  of  it,  the  de- 
lay of  another  fortnight  will  give  a  greater  chance  to  the  child 
surviving  the  birth." 

1667.  There  has  always  been  a  considerable  difficulty  in  ascer- 
taining with  precision  the  degree  of  opening  of  the  superior  strait 
— none  of  the  inventions  for  this  purpose  can  perhaps  be  suffi- 
ciently relied  upon,  to  remove  all  doubt  upon  the  question;  lam, 
however,  of  opinion,  that  the  calipers  of  Baudelocque  are  the  best 
for  this  purpose.  (79)  If  the  subject  have  been  previously  a  mo- 
ther, the  size  of  the  pelvis  may  have  been  pretty  nearly  ascer- 
tained during  the  progress  of  the  labour:  if  she  have  not  been,  it 
will  be  necessary  to  employ  the  finger,  &c.  to  ascertain  its  con- 
dition as  nearly  as  may  be. 

1668.  It  would  seem  to  be  a  rule  founded  upon  experience, 
that  no  advantage  would  be  gained  by  this  operation,  in  a  pelvis 
that  had  not  two  or  two  and  a  half  inches,  complete,  in  its  ante- 
ro-posterior  diameter,  because  a  child  at  seven  months,  would 
require  an  opening  of  that  size  to  permit  it  to  pass;*  and  it  has 
been  almost  universally  supposed,  that  a  child  which  had  not 
tarried  "seven  months  complete"  in  the  uterus,  would  not  live 
after  its  delivery.  This  certainly  must  be  considered  as  a  va- 
luable, general  rule:  and  if  the  state  of  the  pelvis  admit  of  farther 
delay,  it  would  unquestionably  be  to  the  advantage  of  the  child. 

1669.  But  what  shall  be  done,  with  such  women,  whose  pelves 
have  rather  less  than  two  inches.''  shall  they  be  abandoned  to  the 
Csesarean  section,  or  their  children  to  the  crotchet?  either  of  these 
alternatives  is  certainly  terrible;  and  if  nothing  better  present  it- 
self, must  be  submitted  to — it  may,  however,  become  a  profit- 
able inquiry,  to  determine,  (from  what  has  really  happened 
upon  other  occasions,)  the  propriety  of  inducing  labour  at  an  ear- 
lier period  than  seven  months;  say  at  six.  Children  have  lived, 
when  delivered  at  this  period,  where  there  was  no  deformity  of 

*  Madame  Lachapelle  has  ascertained,  that  the  transverse  diameter  of  the 
child's  head  rarely  or  never  exceeds  three  inches,  and  may  be  much  less. 
(1666) 


596  ON  PREMATURE  DELIVERY. 

pelvis  to  contend  with,  (but  this  circumstance,  it  is  true,  may  oc- 
casion a  different  result,)  and  it  perhaps  would  merit  a  trial  in 
cases  of  more  excessive  deformity;  since,  neither  mother,  nor 
child,  can  have  any  greater  injury  offered  them,  than  the  dread- 
ful operations  just  named.  I  have  witnessed  two  instances  of  chil- 
dren living,  (one,  indeed,  at  this  moment  alive,  arrived  at  woman- 
hood, and  mother  of  children,  and  the  other  lived  several  months,) 
the  mothers  of  whom  were,  as  far  as  could  be  ascertained,  not 
more  than  six  months  advanced  in  gestation.  "  Mr.  I.  T.  Cribbs 
relates  the  case  of  Mrs.  R.  aged  forty  years,  the  mother  of  several 
children,  who  was  taken  in  labour  November  2d,  1827.  Her  last 
menstrual  period  was  on  the  15lh  of  April,  so  that  she  could  not 
be  advanced  more  than  twenty-eight  or  twenty-nine  weeks.  The 
labour  continued,  and  the  ovum  was  expelled  entire,  the  mem- 
branes not  havingbeen  ruptured,  but  still  enclosing  the  foetus  and 
liquor  amnii.  On  breaking  them,  the  child  was  found  living,  and 
perfectly  formed.  It  was  able  to  take  the  breast  in  a  day  or  two. 
The  child  at  six  weeks  old,  weighed  two  pounds  and  two  ounces; 
at  ten  months  its  weight  was  twelve  pounds.  Although  '  very 
weakly,'  it  is  able  to  stand  when  leaning  against  a  chair,  and  its 
health  is  not  bad."*  Indeed,  the  account  which  Fortunatus  Lice- 
tus  gives  of  his  own  birth,  which  was  at  between  the  fourth  and 
fifth  months  of  gestation  may  be  given  in  evidence  upon  this  sub- 
ject, as  it  does  not  appear  to  be  treated  as  fabulous  by  the  writers 
on  medical  jurisprudence.  In  the  case  of  Cardinal  de  Richelieu, 
it  was  decreed  by  the  parliament  of  Paris  that  a  child  was  "  via- 
ble" at  the  fifth  month.  And  Hippocrates  had  admitted  that  a 
child  might  live  at  six  months  and  a  few  days.  The  rule  of  via- 
bility, if  we  may  so  term  it,  should  be  taken  from  the  energy  of 
the  vital  powers  of  the  child,  rather  than  from  the  term  of  utero- 
gestation.  And  I  would  be  understood  by  the  term  viability,  the 
capacity  to  sustain  life,  rather  than  the  mere  signs  of  this  condi- 
tion, by  feeble  cries,  and  languid  movements  of  the  limbs — for 
these  may  be  exhibited  by  an  abortion  of  the  fourth  or  fifth  month, 
but  they  will  not  perhaps  possess  the  capacity  for  future  develope- 
ment  at  this  early  period.  I  say  perhaps — for  I  would  not  wish  to 
be  thought  to  call  in  question  the  veracity  of  such  authors  as  have 
declared  in  favour  of  this  early  date.  My  present  impression  is 
and  has  been  for  many  years,  that  children,  who  have  remained 

*  Lond.  Med.  and  Surg.  Journ.  for  November,  1828. 


ON  PREMATURE  DELIVERY.  597 

alive  in  the  uterus  until  the  sixth  month,  might,  under  favourable 
circumstances  of  labour,  &c.  be  very  often  raised.  This  opinion 
is  strengthened  by  a  cnse  which  has  lately  occurred  under  my 
care. 

Mrs.  B.  was  prematurely  delivered  on  the  26th  July,  1831,  af- 
ter a  labour  of  very  moderate  force  of  six  hours.  She  supposed 
herself  advanced  beyond  the  seventh  month.  When  the  foetus 
was  born  it  showed  but  feeble  signs  of  life — it  moaned  rather  than 
cried.  It  was  not  more  than  nine  inches  in  length  ;  and  it  would 
not,  I  think,  have  weighed  more  than  perhaps  eight,  but  certainly 
not  more  than  ten  ounces.  I  had  it  enveloped  in  a  pretty  thick 
covering  of  carded  cotton  ;  its  lips  were  frequently  vvashed  with 
sweetened  water,  and  occasionally  a  little  rennet  whey  was  put 
into  the  mouth,  which  after  a  time  it  would  swallow.  The  me- 
conium was  purged  off  by  the  use  of  a  little  molasses  and  water. 
About  the  twelfth  day  it  was  put  to  the  breast,  which,  after 
repeated  trials,  it  was  found  it  would  draw  feebly :  this  power 
however,  gradually  increased,  so  much  so  indeed,  that  at  the 
beginning  of  the  third  week,  it  sucked  very  well.  At  this  time 
I  permitted  the  nurse  to  put  a  fine  flannel  dress  upon  it,  and  re- 
move the  cotton.  This  day  it  is  four  weeks  old — it  is  much  im- 
proved in  flesh,  strength,  appetite  and  appearance — in  a  word,  it 
gives  every  hope,  that  it  will  continue  to  thrive  and  do  well. 
The  successful  issue  of  this  case,  so  far,  may  be  justly  attributed 
to  the  fostering  care  of  the  friends  of  the  child,  and  its  nurse;  and 
the  entire  exemption  from  the  fatigue  of  dressing  it. 

1670.  Dr.  Hamilton's  rule  of  "viability"  being  determined 
by  weight,  is  altogether  hypothetical — his  minimum  weight  very 
considerably  exceeds  what  we  have  witnessed.  Now,  one  of  the 
children  alluded  to  above,  weighed  at  six  weeks  old,  clothes  and 
all,  but  one  pound  and  three-quarters. 

1671.  It  might  be  worth  the  trial,  in  cases  where  the  choice  is 
so  limited,  as  to  leave  no  alternative,  but  the  crotchet  or  Caesarean 
operation.  I  am  fully  aware  of  all  the  contingences  attendant 
upon  the  proposition,  yet  it  seems  to  hold  out  a  remote  chance  to 
the  child,  without  increasing  the  risk  to  the  mother.  I  know  full 
well  how  frail  and  tender  the  whole  organization  of  the  fojtus  is 
at  this  period;  and  how  many  dangers  await  its  delivery;  but 
with  me,  they  are  not  of  sufficient  force  to  destroy  the  jiossibility 
of  success  ;  for  the  extreme  pliability  of  the  cranial  bones  at  this 
period  gives  promise  that  the  head  may  pass  without  the  brain 


598  ON  PREMATURE  DELIVERY. 

receiving  so  much  injury,  as  to  forbid  all  chance  of  usefulness 
from  the  operation  ;  and  if  it  succeed  once  in  twenty  times,  it  is 
certainly  better  than  opening  the  head  always  ;  or  subjecting  tlie 
mother  to  the  other  dreadful  alternative. 

1672.  '<II.  The  practice  should  never  be  adopted,  till  expe- 
rience has  decidedly  proved,  that  the  mother  is  incapable  of  bear- 
ing a  full-grown  foetus  alive." 

1673.  "  III.  It  is  sometimes  necessary  to  have  recourse  to  the 
perforator  in  a  first  labour,  though  there  may  be  no  considerable 
distortion  of  the  pelvis;  therefore,  the  use  of  this  instrument  in  a 
former  labour,  is  not  alone  to  be  considered  as  a  justification  of  the 
practice." 

1674.  ''  IV.  The  operation  ought  not  to  be  performed  when  the 
patient  is  labouring  under  any  dangerous  disease."  And  I  would 
add,  any  very  acute  disease,  if  not  absolutely  dangerous. 

1675.  "V.  If,  upon  examination,  before  the  operation  is  per- 
formed, it  should  be  discovered  that  the  presentation  is  preterna- 
tural, it  might  be  advisable  to  defer  it  for  a  few  days,  as  it  is  pos- 
sible that  a  spontaneous  alteration  of  the  child's  position  may  take 
place;  particularly,  if  the  presentation  be  of  the  upper  extremities." 

1676.  I  have  introduced  this  rule,  because  I  am  not  certain  that 
it  may  not  be  an  important  one;  but  to  me,  reason  and  experience 
seem  to  be  against  its  fulfilment.  Reason  is  against  it;  because, 
the  length  of  the  child  from  the  points  of  the  nates  to  the  top  of 
the  head,  would  exceed  the  transverse  diameter  of  the  uterus; 
and,  therefore,  it  could  not  perform  the  movement  called  the 
"  Somerset,"  which  would  be  essential  to  such  a  change  of  parts. 
See  Baudelocque,  on  the  movement,  called  "Somerset." 

1677.  And  experience,  I  am  disposed  to  believe,  must  also  be 
against  it,  since  before  the  rupture  of  the  membranes  at  full  time, 
and  when  the  mouth  of  the  uterus  is  even  pretty  well  dilated,  it 
is  very  difficult  som^etimes  to  determine  the  part  which  may  offer  to 
the  finger — I  believe  that  no  accoucheur,  at  full  time,  would  posi- 
tively pronounce  on  the  part  which  may  present  itself  to  the  os 
uteri,  when  the  os  uteri  is  but  little  expanded,  and  the  membranes 
entire.  And  if  he  cannot  at  full  time,  when  it  must  certainly  be 
less  difficult,  and  less  hazardous,  how  can  he,  without  a  prodigious 
risk  of  being  mistaken,  decide  at  seven  months,  when  the  neck  of 
the  uterus  is  not  effaced;  and  when  it  requires  some  force  to  pass 
the  finger;  when  it  must  be  passed  with  great  care  and  delicacy, 
that  the  membranes  be  not  ruptured;  and  where,  did  we  employ 


ON  PRJEMATURE  DELIVERY.  599 

a  pressure  sufficient  to  determine  the  nature  of  the  presenting 
part,  the  membranes  would  almost  certainly  give  way;  I  ask,  un- 
der all  these  disadvantages,  how  can  we  ascertain  with  so  much 
precision,  as  would  render  the  examination  free  from  doubt  as  to 
the  suture  that  may  offer  to  the  finger?  Dr.  James  gives  us  an  in- 
stance in  point,  as  regards  the  delicacy  that  is  necessary  in  this  ex- 
amination; in  this  case  the  membranes  yielded,  by  some  little 
damage  being  done  to  the  membranes  by  a  previous  examination. 
See  his  interesting  case,  Eclectic  Repertory,  Vol.  I.  p.  105. 

1678.  An  anonymous  writer  in  No.  II.  Vol.  V.  of  third  series  of 
the  New  England  Journal,  has  also  questioned  the  possibility  of 
ascertaining  the  precise  nature  of  the  presentation:  or  he  rather 
declares,  that  "it  is  not  very  easy  to  do  it,  even  in  the  earliest 
hours  of  a  labour  which  takes  place  at  the  usual  time,  and  after 
its  most  natural  manner.  Is  it  not  then  to  be  looked  upon  as  al- 
most impossible  in  the  case  supposed,  (of  premature  labour  artifi- 
cially induced,)  where  the  os  uteri,  having  been  opened  merely  by 
the  finger,  or  a  passage  through  it  effected  by  a  small  instrument 
as  far  as  the  membranes?"  But  he  adds,  "  it  is  not  questioned 
that  Denman,  Burns,  and  Merriman,  ascertained  the  presenta- 
tion in  the  cases  in  which  they  waited  before  they  broke  the  mem- 
branes." 

1679.  I  am,  however,  far  from  conceding  so  much  to  the  tact  of 
any  man  under  such  circumstances;  and  for  the  reasons  just  stat- 
ed. And  I  may  add,  that  in  my  opinion,  it  would  be  altogether 
impossible  to  discriminate  between  the  head  and  the  breech;  or 
between  the  feet  and  the  hands.  Besides,  it  would  be  altogether 
unavailing  to  any  useful  end,  to  wait  for  a  favourable  change, 
were  the  presentation  ascertained  to  be  a  preternatural  one, 
agreeably  to  their  acceptation  of  the  term;  as  well  as  unnecessa- 
rily losing  very  important  time;  for  I  agree  perfectly  with  Bau- 
delocque,  and  Ramsbotham,  that  the  change  called  the  "Somer- 
set," cannot  take  place  after  the  sixth  month  of  pregnancy. 

1680.  I  have  insisted  upon  this  view  of  the  subject  the  more, 
because  the  recommendation  of  delay  comes  from  very  high  au- 
thority; as  well  as  from  the  most  entire  conviction  that  if  it  were 
acted  upon,  the  moment  for  a  successful  operation  would  pass,  not 
to  return  again. 

1681.  "  VI.  The  utmost  care  should  be  taken  to  guard  against 
an  attack  of  shivering  and  fever,  which  seems  to  be  no  unusual 
consequence  of  this  attempt  to  induce  uterine  action,  and  has 


600  SECTION  OF  THE  PUBES. 

often  proved  destructive  to  the  child,  as  well  as  alarming  with  re- 
gard to  the  mother.  The  peculiar  circumstances  under  which 
the  operation  is  performed,  and  the  habit  of  body  of  the  patient, 
will  determine  the  accoucheur  either  to  adopt  a  strictly  antiphlo- 
gistic plan,  or  to  exhibit  opium  or  antispasmodics  and  tonics." 

1682.  "  VII.  In  order  to  give  every  possible  chance  for  preser- 
ving the  life  of  the  child,  it  will  be  prudent  to  have  a  wet  nurse 
in  readiness,  that  the  child  may  have  a  plentiful  supply  of  breast 
milk  from  the  very  hour  of  its  birth." 

1GS3.  The  last  direction  would  seem  to  intimate,  that  the  wo- 
man who  has  undergone  this  operation,  is  incapable  of  nursing 
the  child  after  it  is  born — but  this  is  certainly  not  so  always.  1 
have  seen  as  abundant  flows  of  milk  after  premature,  (spontane- 
ous, if  I  may  so  term  them,)  labours,  as  when  the  child  was  car- 
ried to  the  full  time.  Nor  do  I  see  any  good  reason,  why  an  im- 
mature child  should  suffer  more  than  a  mature  one,  for  the  want 
of  "breast  milk"  for  a  few  days — yet  the  caution  may  be  useful. 

1684.  "  Lastly.  Ji  regard  to  his  own  character,  should  deter- 
mine the  accoucheur  not  to  perform  this  operation,  unless  some 
other  respectable  jiractitioner  has  seen  the  patient,  and  has  ac- 
knou)ledged  the  operation  as  advisahleP 

1685.  It  is  not  necessary  to  describe  the  mode  of  operating  in 
this  case;  for,  as  Dr.  Denman  very  justly  observes,  "  No  person 
properly  qualified  to  decide  on  the  propriety  of  this  operation,  can 
be  ignorant  of  the  manner  of  performing  it."  He  cautions  against 
injuring  the  child  in  this  operation — this  cannot  happen,  if  a  blunt 
instrument  be  used  instead  of  a  sharp  one.  Dr.  Campbell  sug- 
"•ests  Avith  much  good  sense,  that  the  less  compression  the  child 
suffers  in  transitu,  the  less  will  be  the  risk  it  may  suffer  from  ute- 
rine compression  ;  and  with  a  view  to  diminish  this,  recommends, 
that  the  membranes  should  only  be  separated  from  the  uterine 
parieties,  by  means  of  a  large  catheter,  or  the  finger  of  the  prac- 
titioner, as  may  from  circumstances  prove  most  convenient,  in- 
stead of  rupturing  them,  affirming  that  this  operation  will  insure 
uterine  contraction  as  certainly,  if  not  as  speedily,  as  expending 
the  liquor  amnii,  by  puncturing  the  ovum.  Ed.  Med.  and  Sur. 
Journ.  for  April,  1830.  p.  315. 

Sect.  VI.— /    Section  of  the  Pubcs. 
1686.   I  should  not  have  enumerated  this  operation  as  one  of  the 
resources  of  the  art,  but  to  have  it  in  my  power  to  declare  it  not 


SECTION  OF  THE  PUBES.  601 

to  be  one — and  tliough  the  operation  has  been  performed  twice, 
lately,  with  success,  it  is  said  ;  (that  is,  the  children  were  born 
alive  and  did  well,  and  the  mothers  recovered  ;)  yet  it  is  evident, 
from  the  relation  of  the  cases,  there  could  have  been  no  very- 
great  deformity  of  Ihc  pelvis,  or  much  room  to  applaud  the  oper- 
ator for  his  <■'  success. "'  For  after  the  operation,  the  patients  were 
placed  in  warm  baths,  and  the  farther  separation  of  the  bones  and 
dilatation  of  the  parts  were  left  to  the  efforts  of  nature.  On  deli- 
very, the  bones  were  found  separated  an  inch  and  a  half,  a  proof 
there  could  not  have  been  much  restriction  of  the  superior  open- 
ing of  the  pelvis,  as  a  separation  of  even  two  inches  gives,  as  a  ge- 
neral result,  but  six  lines,  or  half  an  inch,  in  the  antero-posterior 
diameter  of  the  superior  strait;  therefore,  less  than  half  an  inch 
must  have  been  obtained  in  the  cases  just  mentioned;  yet  with 
that  additional  capacity,  the  women  were  enabled  them  to  deliver- 
selves;  consequently,  there. could  have  been  but  little  deformit}'. 

1687.  Besides,  it  is  stated,  that  in  one  of  the  cases  no  reunion 
of  the  bones  took  place,  owing,  it  is  supposed,  to  their  not  having 
been  placed  in  apposition — this  being  so,  one  of  two  things  must 
account  for  the  defect;  either  that  the  operation  must  have  been 
most  bunglingly  performed,  not  to  have  secured  the  bones  in  ap- 
position; or,  if  this  be  not  admitted,  there  must  be  a  risk  of  union 
not  taking  place,  however  well  performed. 

1688.  But  as  some  have  thought  I  dismissed  this  subject  by  too 
briefly  noticing  it;  and  especially,  as  the  cases  glanced  at  above 
were  instances  of  success,  I  have,  in  compliance  with  the  opinions 
of  some  friends,  whose  opinions  I  respect,  given  the  cases 
alluded  to  as  fully  as  I  could,  and  have  followed  them  with 
some  observations  upon  the  operation,  which  should  be  known 
to  those  who  might  be  seduced  to  perform  the  section  of  the 
pubes  from  the  success  which  followed  it  in  Dr.  Manchini's 
hands. 

1689.  Dr.  Manchini,  professor  of  anatomy  at  Naples,  has  late- 
ly, (1824,)  performed  the  section  of  the  pubes  in  two  instances, 
and,  as  he  says,  with  success.  In  both  of  these  cases  it  was  de- 
clared, in  consultation,  that'' the  delivery  could  not  be  effected 
by  the  natural  process.  In  both  instances  the  children  were  born 
alive,  and  did  well,  and  the  mothers  recovered.  After  the  opera- 
tion, which  consisted  in  a  simple  division  of  the  symphysis,  the 
patients  were  put  into  a  warm  bath,  and  the  farther  separation  of 
the  bones  and  dilatation  of  the  passages  left  to  the  efforts  of  na- 
76 


602  SECTION  OF  THE  PUBES. 

ture."  The  reporter  says,  <'  I  do  not  know  exactly  what  time 
was  necessary  for  this  purpose,  in  the  first  instance;  but,  in  the 
second,  the  delivery  was  accomplished  in  eight  hours  after  the 
operation,  when  the  divided  bones  were  found  to  have  separated 
an  inch  and  a  half  from  each  other.  The  parietal  bones  of  the 
child's  head  overlapped  each  other  very  much,  and  the  whole 
cranium  was  brought  into  the  form  of  a  cone,  from  the  pressure  it 
had  sustained  in  effecting  a  passage  through  the  openings  which 
were  still  narrow." 

1690.  "In  the  first  case,  no  reunion  of  the  divided  parts  took 
place,  owing  to  their  not  having  been  brought  into  apposition  after 
the  delivery;  from  which  circumstance  the  power  of  walking  has 
not  been  recovered,  but  is  performed  in  a  straddling  manner. 
In  the  second  case,  the  parts  were  brought  together  after  the 
accouchrnent,  and  retained  in  their  natural  situation  by  means  of 
rollers  properly  applied;  the  bones  united,  and  no  inconvenience 
of  any  kind  was  afterwards  experienced."* 

1691.  I  have  thought  proper  to  record  these  cases,  as  they  have 
been  received  with  much  complacency  by  a  number  of  the  pro- 
fession, and  considered  as  confirming  the  opinion  of  the  safety  and 
propriety  of  this  operation,  as  promulgated  bj^  Sigault  and  others, 
when  it  first  came  into  vogue.  At  that  period  it  was  consi- 
dered as  a  real  and  important  improvement  of  the  mechanical 
means  of  terminating  such  labours  as  appeared  to  offer  no  alter- 
native, but  the  Caisarean  operation.  Baudelocque  attacked  these 
opinions  with  great  force  of  argument,  derived  principally,  from 
well-directed  and  convincing  experiments  upon  the  dead  and  liv- 
ing subject. 

1692.  The  idea  of  this  operation  was  first  suggested  by  a 
passage  in  the  works  of  Severin  Pineau,  to  M.  Sigault,  while  a 
student  of  medicine,  in  1768,  and  was  first  performed  by  himself  in 
1777,  with  success. 

1693.  It  was  originally  intended  to  supersede  the  Coesarean 
operation  in  such  cases  as  was  thought  could  only  be  terminated 
by  that  method.  But  its  partisans  soon  employed  it,  in  cases 
where  patience  or  a  well-directed  choice  of  other  means,  might 
have  succeeded;  and  consequently,  it  was  often  unnecessarily,  if 
not  wantonly  performed;  for  we  are  informed,  that  it  was  had  re- 
course to  more  frequently  in  the  period  of  four  or  five  years,  than 

*  Andei-son's  Quarterly  Journal,  Vol.  I,  No.  1.  p.  149. 


SECTION    OF    THE    PUBES.  603 

the  Caesarean  opeiation  in  twenty  or  thirty,  or  even  in  half  a  cen- 
tury. In  a  word,  liaudelocque  says,  '<  that  the  whole  art  of  mid- 
wifery was  reduced,  so  long  as  the  delirium  continued,  to  a  dex- 
terity in  performing  this  operation;  its  partisans  ventured  to 
publish,  that  the  operation  itself  was  a  trifle;  and  that  everything 
depended  upon  the  subsequent  treatment." 

1694.  It  was,  however,  very  early  shown,  especially  by  Bau- 
delocque,  that  the  original  suggestion  of  this  operation  by  M.  Si- 
gault,  as  a  substitute  for  the  Caesarean  section,  was  founded  in 
error;  for  the  latter  operation  is  only  proposed,  where  it  is  phy- 
sically impossible,  that  a  child  at  full  time  can  be  born  alive;  or 
to  reduce  it  to  greater  precision,  where  there  is  less  than  two 
inches  and  three-quarters  in  the  antero-posterior  diameter  of  the 
superior  strait.  Now  as  there  are  constantly  deviations  from  the 
measurement  just  named,  to  that  of  a  few  lines,  it  must  follow, 
that  there  must  be  gained  an  increase  of  diameter,  equal  to  the 
space  admitted  above,  that  the  operation  shall  be  successful.  This 
being  granted,  (for  it  cannot  be  disputed  that  M.  Sigault  pro- 
posed his  operation  as  a  means  to  save  the  life  of  both  mother  and 
child,)  it  only  remained  for  the  opposers  of  his  plan,  to  show;  first, 
the  greatest  possible  increase  of  diameter  that  can  be  obtained 
by  the  separation  of  the  ossa  pubis;  and  second,  the  least  possi- 
ble diameter  to  which  the  head  can  be  reduced  with  safety. 

1695.  It  was  accordingly  shown  by  Baudelocque  and  others, 
that  the  greatest  possible  gain  by  this  operation  in  the  antero- 
posterior diameter  of  the  upper  strait,  on  the  dead  subject,  is 
from  five  to  six  lines  French,  or  about  half  an  inch  English;  and 
consequently,  insufficient  in  inany  instances  for  the  object  for 
which  it  was  instituted;  namely,  to  preserve  the  lives  of  both  mo- 
ther and  child.  It  was  also  shown,  that  the  transverse  diame- 
ter of  the  child's  head  would  not  bear  with  impunity  a  reduction 
below  three  inches,  or  a  very  kw  lines  less  than  its  natural  diame- 
ter; and  of  course,  that  this  operation  would  fail,  when  the  ante- 
ro-posterior diameter  could  not  be  increased  to  at  least  three 
inches.  For  it  is  well  ascertained,  that  the  ordinary  diameter  of 
the  child's  head  from  one  parietal  protuberance  to  the  other,  is 
rarely  less  than  three  inches  and  a  half,  in  a  full  grown  foetus. 

1696.  These  povverful  objections  were  early  urged  against  this 
operation;  and  without  taking  into  calculation  at  that  time  the 
mischiefs  that  might  accompany  it,  as  these  were  to  be  tested  by 
farther  experience.     A  short  period,  however,  served  to  prove. 


(304  SECTION  OF  THK  PUBES. 

that  almost  every  operation  had  a  victim,  as  the  life  of  the 
child  was  rarely  preserved,  and  the  mother  very  often  fell  a 
sacrifice. 

1697.  Frequent  opportunities  presented  themselves  in  the  Ho- 
tel Dieu  of  Paris,  in  consequence  of  the  prevalence  of  a  very  fatal 
epidemic,  to  ascertain  with  every  necessary  precision  on  the  dead 
subject,  the  space  that  could  be  gained  by  the  division  of  the  pubes. 
The  following  is  Baudelocque's  account  of  the  experiments  made 
by  himself  and  others  at  that  time. 

1698.  "The  subject  being  placed  upon  a  table,  the  thighs  mo- 
derately separated  by  two  assistants,  the  ossa  pubis  receded  from 
each  other  from  three  to  six  lines,  the  instant  the  section  was 
made.  It  was  not  without  carrying  the  thighs  forcibly  outwards 
so  as  to  make  them  in  several  of  the  women  describe  right  angles 
with  the  trunk,  or  the  form  of  the  letter  T,  that  we  could  obtain 
a  separation  of  two  inches  and  a  half;  and  even  then  we  vvere 
obliged  to  pull  the  hips  in  the  same  direction  as  the  inferior  ex. 
tremities.  That  separation  was  not  obtained  in  any  one  instance 
without  tearing  the  sacro-iliac  symphyses,  and  that  tearing,  which 
began  sooner  or  later,  was  more  or  less  considerable,  according 
to  the  particular  form  of  the  pelvis  on  which  we  operated,  and  as 
the  symphyses  themselves  were  more  or  less  supple." 

1699.  "  In  a  pelvis  whose  superior  strait  had  but  three  inches 
and  a  quarter  in  the  small  diameter,  and  five  inches  transversely, 
the  ossa  pubis  were  scarcely  separated  an  inch,  before  one  of  the 
sacro-iliac  symphyses  appeared  open  a  line  and  a  half,  and  the 
other  only  a  line.  The  separation  of  the  former  augmented  to  five 
lines,  and  that  of  the  latter  to  three  and  a  half;  the  periosteum 
detached  itself  from  the  bones  to  a  considerable  distance,  and  their 
anterior  ligaments  were  torn  long  before  the  ossa  pubis  were  se- 
parated two  inches  and  a  half.  In  another  experiment  on  a 
pelvis  of  four  inches  seven  lines  in  the  small  diameter,  and  four 
inches  and  three-quarters  in  the  other  direction,  the  ossa  pubis 
could  not  be  separated  twenly-one  lines  without  detaching  the 
periosteum  from  the  sacro-iliac  symphyses,  and  tearing  it  an  inch 
before  them.  The  symphyses  themselves  were  opened  so  far  as 
to  admit  the  end  of  the  finger,  and  in  the  sequel  separated  so  as 
to  receive  the  end  of  the  thumb  with  ease." 

1700.  "  The  external  wound,  which  was  two  inches  and  a 
half,  was  torn  in  all  these  cases,  as  well  at  the  superior,  as  at  the 


SECTION  OF  THE  VITBES.  605 

inferior  anglo:  and  soniclimes  to  tlic  extont  of  several  fingers' 
breadth." 

1701.  The  experiments  of  Ripping,  Serin,  Chevreal,  Desgran- 
ges,  Siebold,  &c.  were  generally  in  strict  conformity  to  those  of 
of  Baudelocque  and  his  friends,  and  tended  very  much  to  support 
them.  The  combined  results  of  these  trials,  prove  undeniably, 
that,  the  small  diameter  of  the  superior  strait,  cannot  be  increased 
beyond  four  or  five  lines,  even  when  the  ossa  pubis  are  separated 
two  inches  and  a  half,  which  cannot  destroy  the  disproportion, 
as  we  have  already  said,  which  exists  between  the  child's  head 
and  the  pelvis  in  the  cases  for  which  this  operation  was  originally 
proposed,  if  even  this  degree  of  separation  could  with  safety  be 
obtained  on  the  living  woman. 

1702.  Besides,  Baudelocque  very  justly  calls  in  question  the 
necessity  of  this  operation  in  some  of  the  .cases  in  which  this 
operation  was  said  to  triumph,  by  rendering  it  very  much  more 
than  probable,  that  the  openings  of  the  superior  straits,  were  con- 
siderably greater  than  those  ascribed  to  them;  consequently,  the 
degree  of  enlargement  procured  by  the  section  of  the  pubes  was 
exaggerated.  And  this  was  confirmed  in  a  number  of  instances, 
by  the  woman  who  suffered  the  operation  being  delivered  previ- 
ously or  subsequently,  without  adventitious  aid. 

1703.  Though  the  section  of  the  pubes  purports  to  be  a  safer 
and  an  easier  operation  than  the  Caesarean,  it  is  not  found  to  be 
so,  in  the  general.  That  it  has  been  occasionally  successful  as  re- 
gards the  mother  and  child,  must  not  be  denied;  but  it  would 
seem  in  all  these  instances,  to  have  been  performed  when  this 
operation  was  not  absolutely  necessary;  or  when  the  milder  and 
safer  operation  of  premature  delivery  would  have  been  the  better 
mode  of  treating  such  cases.  Even  after  an  increase  of  diameter 
is  procured  by  the  section  of  the  symphysis  pubis,  there  is  no  se- 
curity, that  much  after-difficult}^  will  not  present  itself;  for  the 
delivery  has  been  afterwards  effected  by  forceps  and  other  means, 
without  entire  safety  to  the  child;  for  in  most  instances,  it  was 
either  still-born  or  died  very  soon  after  its  delivery. 

1704.  But  were  it  admitted,  that  the  necessary  room  can  be 
procured  when  all  the  parts  concerned  are  favourably  disposed, 
it  is  very  far  from  certain,  that  this  will  obtain  in  the  majority  of 
cases.  For  it  has  been  found  absolutely  necessary  to  use  the  saw 
for  the  separation  of  the  symphysis,  owing  to  its  unnatural  con- 
solidation; and  it  has  ocu^urred  that,  when  the  division  has  been 


606  SECTION  OF  THE  TUBES. 

made,  that  a  separation  of  the  extremities  of  the  divided  bones 
could  not  be  procured,  in  consequence  of  the  ossification  of  the 
sacro-iliac  symphyses.  Now,  we  are  informed,  that  this  condi- 
tion of  these  parts  is  not  very  rare;  but  it  cannot  be  known,  until 
after  the  operation  has  rendered  such  knowledge  useless. 

1705.  This  operation,  as  a  general  rule,  is  very  far  from  being 
safe  to  the  child;  for  out  of  thirty-three  operations,  but  thirteen 
were  saved;  all  the  others  died,  either  before  the  operation,  or 
during  the  extraction;  and  it  must  be  remarked  that  the  children 
which  were  preserved,  belonged  to  women  whose  pelves  were 
the  least  deformed;  consequently,  this  operation  cannot,  as  re- 
gards the  child  at  least,  be  considered  as  a  substitute  for  the  Cae- 
sarean  section. 

1706.  The  evils  of  this  operation,  however,  are  not  confined  to 
the  child;  the  mother  also  is  often  a  severe  sufferer:  for  when  the 
deformity  is  extreme,  she  is  sure  to  die.  Of  tiie  thirty-three  cases 
just  noticed,  twelve  evidently  died  of  the  consequences  of  the  ope- 
ration; and  of  those  who  survived,  the  greater  number  had  been 
delivered  naturally  before,  or  safely  delivered  since;  while  seve- 
ral always  remained  infirm. 

1707.  Beside  the  grave  evils  just  enumerated,  there  are  many 
of  a  minor  kind,  which  are  every  way  worthy  of  consideration, 
since  they  but  too  often  have  entailed  misery  upon  the  unfortunate 
females  who  were  the  subjects  of  the  operation.  Among  these 
may  be  mentioned  all  the  inconveniences  which  must  follow  the 
separation  of  the  cartilages  from  the  ossa  pubis,  and  the  iliac 
junctions;*  irremediable  sloughings  from  the  neck  of  the  uterus, 
and  the  external  parts;  collections  of  pus,  or  sanies  in  the  cellu- 
lar tissue  of  the  pelvis;  hernia  of  the  bladder  between  the  ossa 
pubis;  extravasations  in  the  psoae  muscles;  injury  to  the  urethra; 
incontinence  of  urine;  gangrene,  &c. 

1708.  We  may  also  with  much  propriety  notice  the  evil  which 
followed  one  of  the  cases,  which  gave  rise  to  the  present  observa- 
tions; namely,  the  incapacity  to  walk  firmly.  And  though  it  is 
expressly  stated  this  arose  from  neglect,  it  is  nevertheless  one  of 
the  penalties  of  this  operation;  for  we  hardly  dare  admit  that  an 
operation  of  such  moment  could  have  been  conducted  with  such 
reprehensible  carelessness. 

1709.  From  what  we  have  said  upon  the  subject  of  the  section 

*  See  Chapter  on  Separation  of  the  Bones  of  the  Pelvis. 


SECTION    OF    THE    PUBES.  607 

of  the  symphysis,  we  may  safely  draw  the  following  important 
conclusions: — 

1710.  First.  That  it  can  never  be  a  substitute  for  the  Csesarean 
operation,  except  the  pelvis  to  be  operated  upon,  has  two  inches 
and  three-quarters  in  the  antero-posterior  diameter;  and  even 
when  it  possesses  this  capacity,  it  is  certainly  more  dangerous  both 
to  mother  and  child,  than  premature  delivery,  when  the  choice 
is  at  command. 

1711.  Second.  That  this  operation  is  almost  necessarily  fatal 
to  the  child,  where  the  deviation  is  very  little  below  what  we 
have  just  stated  it  should  be,  to  render  this  operation  even  pro- 
bably safe. 

1712.  Third.  That  in  every  instance  in  which  the  ossa  pubis 
have  been  separated  two  inches  and  a  half,  it  has  proved  fatal  to 
the  woman,  and  not  always  safe  to  the  child. 

1713.  Fourth.  That  it  has  not  been  always  safe  where  the  an- 
tero-posterior diameter  has  had  two  inches  and  a  half,  nor  always 
successful  when  the  opening  has  been  more  ample,  or  in  other 
words,  even  where  it  should  not  have  been  performed,  because  it 
was  not  indicated. 

1714.  Fifth.  When  more  than  five  or  six  lines  have  been  pro- 
cured in  the  little  diameter  of  the  upper  strait,  it  has  always  been 
upon  the  dead  subject,  and  always  at  the  expense  of  the  unions 
of  the  ilia  with  the  sacrum;  and  would  consequently  be  fatal  to 
the  living  subject;  for  more  than  two  or  three  lines  cannot  be 
procured  in  this  direction  without  serious  inconvenience. 

1715.  Sixth.  That  this  operation  should  never  be  performed, 
when  advantage  can  be  taken  of  delivering  at  the  seventh  month, 
in  a  pelvis,  whose  diameter  at  the  superior  strait,  shall  have  two 
inches  and  a  half,  or  upwards. 

1716.  Baudelocque  concludes  his  inimitable  analysis,  by  say- 
ing, "the  s|;ctioa  of  the  pubes  cannot,  at  present,  maintain  any 
comparison  with  the  Cassarean  operation;  at  most  it  might  be  sub- 
stituted for  the  forceps,  in  some  particular  cases  only;  for  it  can- 
not, without  great  inconveniences,  give  an  increase  of  more  than 
two  lines  from  the  pubes  to  the  sacrum,  superiorly;  and  that  in- 
strument may  without  danger,  reduce  the  diameter  of  the  child's 
head  that  much.  But  what  practitioner  would  prefer  a  new  ope- 
ration, which  seems  to  be  surrounded  by  rocks  on  every  side,  to 
one  that  has  been  crowned  with  a  thousand  successes  ?  If  we  al- 
low the  former  any  advantages,   they  would  never  be  more  evi- 


608  REGIMEN. 

dent  than  in  that  species  of  locked  head  mentioned  by  Roederer, 
where  we  cannot,  says  he,  introduce  any  instrument  between 
the  head  and  the  pelvis,  at  whatever  part  it  may  be  attempted  ; 
in  this  case  it  would  merit  a  preference  over  opening  the  cra- 
nium, the  use  of  the  crotchets,  and  the  Coesarean  section,  as 
proposed  by  the  same  author;  it  would  be  preferable,  also,  where 
the  inferior  strait  is  contracted  irunsversdy,  provided  a  small 
separation  were  sufficient  to  give  that  diameter  the  necessary 
extent." 

1717.  The  doctrines  here  taught,  are  in  strict  conformity  with 
those  inculcated  throughout  the  works  of  this  very  able  accou- 
cheur; but  they  will  nevertheless  fail  to  be  guides  to  very  many 
of  the  profession;  this  diversity  will  arise  from  several  causes. 
First,  to  the  estimate  which  will  necessarily  be  made  of  the  value 
of  the  child's  life,  and  the  risk  the  mother  would  run  from  the 
section  of  the  pubes.  Second,  to  the  capacit)^  the  practitioner 
may  possess  of  perlbrming  the  operation.  Third,  to  the  influence 
of  public  opinion.     Fourth,  to  the  force  of  education. 

1718.  In  the  cases  which  have  given  rise  to  these  observations, 
Dr.  Manchini  pursued  a  novel  plan  after  the  operation;  namely, 
placing  his  patients  in  the  warm  bath.  We  are  not  prepared  to 
say  how  far  this  step  may  have  contributed  to  the  success  of  the 
enterprise;  though  disposed  at  first  sight  to  believe  it  may  be  a 
great  improvement  in  cases,  where  the  acquired  room  has  been 
sufficient  to  permit  the  child's  head  to  pass  without  additional 
force,  and  where  the  pains  continue  with  force  and  tolerable  regu- 
larity. We  would  think  it  might  be  useful,  in  such  cases  to  ad- 
minister the  ergot,  where  the  contractile  force  of  the  uterus  is 
found  to  flag,  rather  than  to  call  in  the  use  of  the  force])s,  or  other 
foreign  aid.  For  one  of  the  causes  above  related  is  instructive; 
it  teaches  us,  that  the  child  may  be  born  alive,  by  waiting  pa- 
tiently a  few  hours.  Had  these  cases  come  to  us  *ngre  in  detail, 
they  might  perhaps,  have  been  more  instructive. 

Sect.  VIII. — g.  Regimen. 

1719.  It  was  long  taught,  that  the  child  was  entirely  depen- 
dent upon  the  mother  for  its  nourishment  while  in  utero;  and 
that  for  the  increase  of  the  body,  it  was  coastanlly  necessary  to 
have  a  supply  of  it;  that  tliis  increase  of  the  body  was  in  propor- 
tion to  this  supply;  and  consequently,  the  ingesta  of  the  mother, 
must  have  a  decided  control  upon  the  size  of  the  child — hence, 


KKGIMEN.  609 

a  woman  with  a  deformed  pelvis,  has  heen  advised  to  live  very 
abstemiously  with  a  view  to  diminish  the  size  of  the  child.  This 
speculation  was  both  natural  and  ingenious;  and  there  is  perhaps 
but  one  argument  against  it;  namely,  that  experience  has  not 
proved  it  to  be  well-founded.  This  scheme,  therefore,  is  now, 
entirely,  I  believe,  abandoned.  Dr.  Holcombe,  however,  has  late- 
ly revived  it  in  a  letter  to  the  author,  where  he  has  related  seve- 
ral instances  of  success  from  a  combination  of  diet  and  medicines, 
in  considerable  deformiiies  of  pelvis;  and,  as  everything  which 
has  a  tendency  to  preserve  life,  to  diminish  danger,  or  to  alleviate 
the  sufferings  of  child-bearing,  must  be  highly  interesting,  I  trust 
we  shall  be  doing  an  acceptable  office,  in  transferring  the  Doctor's 
observations  on  this  important  subject  to  our  pages,  in  his  own 
words. 

"Regimen  is  another  subject  but  briefly  noticed  in  your  work- 
in  the  short  chapter  which  you  devote  to  it,  you  merely  observe, 
experience  has  proved,  that  lessening  the  quantity  of  food  on  the 
part  of  the  mother,  has  no  influence  upon  the  size  of  the  child — 
or  words  to  this  effect.  My  attention  has  been  turned,  for  some 
years  past,  with  much  interest  to  this  subject;  and  I  have  been 
led  to  believe  from  the  result  of  several  cases,  that,  by  means  of 
a  medicinal  regimen,  the  size  of  the  foetus  in  utero,  may  be  very 
sensibly  lessened,  without  jeoparding  its  safety,  or  seriously  im- 
pairing the  health  of  the  mother:  so  much  so,  that  a  child  which 
would  otherwise  weigh  at  birth  ten  pounds,  may  be  made  to  weigh 
five  pounds!  My  ojjinion  is  founded  upon  the  following  facts:  in 
June,  1817,  I  delivered  with  the  crotchet,  (the  forceps  and  ergot 
had  failed,)  after  a  fearful  labour  of  sixty  hours,  a  lady  with  her 
first  child.  She  was  thirty-two  years  of  age,  and  had  a  pelvis 
more  deformed  than  any  I  have  ever  met  with.  In  fact,  it  is  the 
only  pelvis  actually  deformed,  which,  in  a  practice  of  sixteen 
years,  I  have  had  to  contend  with.  This  lady  soon  conceived 
again.  Her  child,  however,  perished  about  the  seventh  month, 
but  was  not  expelled  until  the  eighth;  and  then,  notwithstanding 
it  was  in  a  state  of  putrefaction,  the  labour  was  protracted,  severe, 
and  difficult,  I  ought  to  mention  here  that  the  first  child  weighed 
ten  pounds  and  a  half,  and  the  second,  had  it  lived,  would  to  all 

appearance  have  attained  tlie  same  size.     Mrs. soon  found 

herself  pregnant  again,  but  almost  immediately  afterwards  began 
to  complain  of  symptoms  of  general  dropsy,  which  required  for 
their  suppression  the  daily  use  of  medicines,  during  the  whole 
77 


610  REGIMEN. 

period  of  gestation— particularly  a  pill  composed  of  calomel,  squills, 
and  digitalis.  The  calomel  kept  her  system  almost  entirely  under 
the  mercurial  influence;  and  the  squills  and  digitalis  assisted  in 
nauseating  her  stomach  from  day  to  day.  At  the  close  of  a  full 
period,  she  was  delivered  of  a  healthy  child,  weighing  four  pounds 
and  a  half,  after  a  very  sharp  labour  of  five  hours!  The  remark- 
able difference  between  this  child  and  the  two  first,  struck  me 
forcibly;  and  I  was  disposed  to  account  for  it,  by  referring  it,  in  a 
great  measure,  to  the  medicinal  treatment  to  which  the  mother 
had  been  subjected;  and  I  was  determined  to  test  the  accuracy 
of  the  conjecture,  by  direct  experiment,  as  soon  as  a  proper  case 
should  come  within  my  control.  One  soon  occurred.  A  preg- 
nant woman,  who  had  never  borne  a  living  child,  but  lost  three, 
two  of  them  by  instrumental  delivery,  was  easily  prevailed  upon 
to  submit  to  a  course  of  medicines,  by  the  prospect  held  out  to  her 
of  an  easy  labour  and  a  living  child.  She  commenced  her  course 
about  the  fourth  month  of  gestation,  and  continued  it  very  per- 
severingly  until  delivery,  which  was  effected  without  difficulty. 
The  child,  (which  was  alive  and  healthy,)  I  did  not  see,  being  ab- 
sent from  the  neighbourhood,  but  was  assured  that  it  was  i-ather 
smaller  than  children  usually  are,  weighing  perhaps  about  five 
and  a  half  or  six  pounds.  Her  other  children  had  weighed  from 
ten  to  twelve  pounds.  One  of  them  I  saw  and  weighed  myself. 
It  rather  exceeded  eleven  pounds.  The  efiect  of  treatment,  in 
this  case,  I  considered  decisive,  and  I  was  confirmed  in  this  opi- 
nion by  this  woman's  next  child,  which  weighed  eleven  pounds 
and  was  expelled  by  means  of  ergot,  after  a  most  painful  and  diffi- 
cult labour  of  forty  hours.  The  woman  had  refused,  during  ges- 
tation, to  submit  to  treatment,  or  rather  her  husband,  (having 
been  ridiculed  by  his  associates  on  account  of  his  dwarf — a  plumj), 
healthy  little  thing,  by  the  way,  as  any  in  the  neighbourhood,)  had 
compelled  her  to  refuse.  Since  this  case,  several  other  women 
have  submitted  to  medicinal  regimen,  and  the  result  has  been  uni- 
formly the  same:  the  child  in  every  case  being  ccnsiderably  re- 
duced in  size,  but  born  alive,  and  to  all  appearances,  with  unim- 
paired health  and  constitution.  Thus,  sir,  have  five  women,  (four 
of  which  had  never  borne  a  living  child,)  been  delivered  of  living 
children,  with  comparative  ease,  by  means  of  a  medicinal  regi- 
men. In  four  of  the  cases  the  woman  had  lost,  (whether  neces- 
sarily or  not,  I  cannot  say,)  by  the  crotchet  and  other  means, 
eleven  children.     In  the  fifth  casC;  the  labour  preceding  the  one 


REGIMEN.  611 

which  I  have  noticed  was  frightfully  severe,  in  consequence  of  the 
extraordinary  weiglit  of  the  child — fourteen  pounds!  Delivery 
was  effected  with  great  difficulty  by  embryotomy.  In  the  next 
labour,  (the  one  treated,)  the  child  weighed  but  four  pounds!  and 
although  a  breech  presentation,  was  expelled  in  a  few  pains.  I 
intend  to  put  this  question  at  rest,  if  opportunities  offer,  by  far- 
ther experiments.  Permit  me,  however,  to  entertain  in  the  mean- 
time, with  great  confidence,  the  following  opinion:  that  women 
with  faulty  pelves,  may  be  enabled  by  means  of  a  rigid  course  of 
medicinal  regimen,  to  bear  children  alive,  who  could  not  by  any 
other  known  method. 

"  To  illustrate  more  fully  my  practice,  I  will  detail  to  you  the 
treatment  of  a  single  case. 

"June  1st,  1819. — Mrs. ,  aged  twenty-four  years,  is  preg- 
nant with  her  fourth  child — has  lost  three  children — owing,  I 
was  told,  to  their  uncommon  size  and  her  contracted  pelvis— is 
supposed  to  be  about  four  months  advanced  in  gestation — is  will- 
ing to  submit  to  any  kind  of  treatment,  however  severe,  to  pro- 
cure an  easy  labour  and  be  the  mother  of  a  living  child.  Let  her 
take  a  pill  of  the  following  prescription,  morning,  noon,  and  night 
— take  also,  twice  a  week,  forty  drops  of  laudanum,  and  be  bled 
every  month. 

<•-  R.  Squills,  48  grs.— Calomel,  18  grs.— digitalis,  6  grs.— Make 
twenty-four  pills. 

"August  1st. — Has  taken  the  pills,  with  a  few  short  intermis- 
sions, very  regularly — mouth  slightly  sore — appetite  impaired — 
feels  feeble  and  dejected,  but  is  willing  to  persevere  in  the  treat- 
ment.     Has  taken  the  laudanum  and  been  bled  twice. 

"Let  her  take  three  grains  of  squills,  night  and  morning — lau- 
danum three  times  a  week,  and  continue  the  bleeding.  As  soon 
as  the  mouth  is  well,  resume  the  calomel  and  digitalis. 

"October  1st. — Resumed  the  calomel  and  digitalis.  August 
lOih — and  has  continued  the  calomel,  with  short  intervals  of 
omission,  constantly  since— has  omitted  the  digitalis  every  other 
week.  Continue  the  treatment;  increasing  the  squills  as  far  as 
the  stomach  will  bear — omit  the  digitalis.  Take  fifty  drops  of 
laudanum  every  other  day. 

"  November  17th. — Delivered  yesterday,  after  a  labour,  of  six 
hours,  of  a  plump,  healthy  looking-child,  weighing  five  and  a  half 
pounds.     Her  other  children  had  averaged  ten  pounds ! 

"  Had  I  the  management  of  a  case  of  more  than  usual  deformi- 


612  REGIMEN. 

ty  of  pelvis,  I  would  commence  the  treatment  as  soon  as  concep- 
tion was  fully  ascertained,  and  put  the  patient  under  a  full  course 
of  various  medicines,  particularly  of  opiates  and  mercurials,  which 
I  would  urge  throughout  gestation,  as  far  as  a  prudent  regard  for 
the  mother  and  child  would  permit. 

''It  would  be  very  gratifying  to  me,  if  you  would  give  the 
regimen  which  I  have  suggested,  a  fair  trial  in  your  practice, 
whenever  a  proper  case  shall  offer.  Cases  of  deformed  pelvis 
are  seldom  found  in  the  country.  Our  resort  to  the  use  of  the 
crotchet  is  constantly  owing  to  the  increased  size  of  the  child, 
rather  than  a  want  of  capacity  in  the  pelvis. 

"The  principle  upon  which  my  practise  is  founded,  is  briefly 
this:  to  derange  digestion,  and  keep  the  liver,  that  great  labora- 
tory of  nutrition,  in  a  constant  state  of  morbid  excitement.  In 
confirmation  of  my  theory,  I  have  collected  a  number  of  cases  of 
very  small  children,  following  bilious  and  other  fevers,  in  which 
much  medicine,  particularly  mercury,  had  been  used.  You  have 
frequently  noticed,  I  presume,  the  same  fact.  Habitual  opium- 
takers  also  bear  small  children.  There  is  a  remarkable  case  of 
this  kind,  at  this  moment  travelling  the  round  of  the  newspapers, 
copied  from  some  of  the  British  Journals."* 

1720.  The  whole  thot  Dr.  Holcombe  has  urged  upon  the  efli- 
cacy  of  regimen  and  medicine  to  diminish  the  size  of  the  foetus 
in  utero,  is  well  deserving  attention,  especially  in  Europe,  where 
the  necessity  is  much  more  frequent,  as  well  as  much  greater 
than  in  this  country.  The  combination  of  medicine  and  regimen 
may  overcome  difficulties  tiiat  would  not  yield  to  either  alone. 
Yet  I  cannot  but  feel  strong  doubts  of  the  united  powers  in  all 
cases  under  consideration.  Certain  it  is,  I  have  seen  strong  and 
robust  children  born  from  consumptive  parents,  and  this  even  in 
the  last  stages  of  it,  where  the  emaciation  was  great  and  the  de- 
bility extreme.  I  never  met  with  but  one  decided  exception  to 
this;  and  this  was  in  the  case  related  in  my  "Essay  upon  Retro- 
version of  the  Uterus;"  and  certain  it  is,  I  have  seen  healthy  and 
large  children  from  mothers  who  had  been  profusely  salivated; 
yet  the  union  of  abstemiousness  with  purging  and  salivation,  may 
effect  the  desirable  reduction  of  the  foetus. 

•  See  his  letter,  in  the  Phil.  .Jour.  Med.  Sciences,  Vol.  II.  New  Series,  p.  322. 


613 


CHAPTER  XLI. 


II.  III.   MONSTROSITY  AND  ACCIDENTAL  DEFORMITY. 

1721.  Both  of  these  may  render  it  necessary  to  mutilate  the 
child,  even  in  a  well-formed  pelvis;  for  they  may  produce  a  re- 
lative narrowness  of  this  cavity — no  certain  rules  can  he  laid  down 
for  the  former,  since  their  peculiarity  cannot  be  ascertained  be- 
forehand— much  must  then  be  left  to  the  good  sense  and  discre- 
tion of  the  practitioner.  One  thing,  however,  is  certain,  monsters 
can  only  interfere  with  labour  from  an  excess  of  parts — should 
the  pelvis  then  be  faulty,  it  may  subject  the  woman  to  all  the 
penalties  of  a  positively  deformed  pelvis.  The  accidental  defor- 
mity can  rarely  cause  a  more  serious  evil  than  delay  in  a  well- 
formed  pelvis,  though  it  may,  in  a  narrow  one,  create  all  the  em- 
barrassments of  a  too  narrow  cavity — when  the  head  or  abdomen 
are  dropsical  in  a  well-formed  pelvis,  perforating  them  will  al- 
most always  relieve  the  woman  by  the  evacuation  of  the  water; 
but  in  a  narrow  pelvis,  this  is  not  sufficient;  since  by  that  opera- 
tion only  the  excess  of  size  is  removed.  I  once  saw  rupture 
of  the  uterus  from  a  hydrocephalic  head.  See  "  Essay  on  Rup- 
ture of  the  Uterus,"  by  the  author. 


614 


CHAPTER  XLII. 


UNCERTAINTY    OF    THE    CHILD'S    DEATH. 

1722.  In  many  instances,  it  would  be  highly  important,  could 
we  determine,  with  certainly,  that  the  child  was  dead  while  in 
utero — it  would  serve  to  abridge  the  sufferings  of  the  mother,  and 
sometimes  would  spare  the  accoucheur  a  deep  drawn  sigh ;  but 
this  is  a  matter  of  great  difficulty  as  well  as  oftentimes  of  great 
moment  to  decide.  All  the  commonly  enumerated  signs  have  been 
known  to  fail,  and  even  when  many  of  the  strongest  were  united; 
of  this,  Baudelocque*  gives  us  a  most  memorable  and  interesting 
example — an  example  that  should  be  well  studied,  and  carefully 
treasured  against  the  time  of  need. 

1723.  The  too  implicit  reliance  upon  certain  of  the  signs  which 
are  said  to  characterize  the  loss  of  life  in  the  child,  has  been  the 
cause  of  the  immolation  of  thousands;  and,  we  cannot  too  earnestly 
deprecate  this  facility  of  credence,  when  we  have  but  too  much 
reason  to  wish  it  were  so.  There  are  but  two  unequivocal  signs 
of  the  child's  death;  namely,  a  cessation  of  pulsation  in  the  um- 
bilical cord  when  prolapsed;  and  the  scalp  forming  a  soft  tumour 
in  which  the  bones  of  the  cranium  can  be  felt  loose  and  detached; 
resembling  much  in  feel,  the  distended  membranes. 

1724.  The  escape  of  offensive  gas;  a  separation  of  the  cuticle 
or  hair ;  a  rolling  motion  within  the  abdomen  ;  a  shrinking  of  the 
abdomen:  and  the  cadaverous  appearance  of  the  woman — are  but 
uncertain  signs  of  the  child's  death.  Velpeau  says,  among  other 
signs,  "  the  death  of  the  child  is  declared  during  labour,  by  the 
escape  of  the  meconium."  We  sincerely  hope,  that  the  young  prac- 
titioner may  never  take  this  for  the  sign  of  the  child's  death;  as 
this  appearance  every  now  and  then  takes  place,  when  the  child 
is  in  the  most  perfect  health.  We  have  known  it  to  happen  at 
least  twice,  in  presentations  of  the  head,  and  pretty  frequently 
when  the  breech  has  been  the  presenting  part.  For  the  meco- 
nium to  escape  from  the  rectum,  it  appears  only  necessary  that 
the  child's  abdomen  should  be  pretty  strongly  compressed. 

*  System,  par.  1898. 


615 
CHAPTER  XLIII, 

ON  THE  SECALE  CORNUTUM,  OR  ERGOT.* 

1725.  I  HAVE  often  had  occasion  to  mention  this  substance  as  a 
powerful  auxiliary  in  the  practice  of  midwifery,  and  as  it  has  ob- 
tained throughout  this  country,  as  well  as  in  Europe,  a  high  repu- 
tation, it  may  be  well  to  inquire  into  its  pretensions.  I  am  more 
anxious  to  do  this,  as  the  claims  of  the  ergot  have  been  extrava- 
gantly urged  in  some  instances,  while  in  others,  the  employment 
of  it  has  been  as  seriously  deprecated;  nay,  it  has  been  condemned 
in  a  few  instances  as  useless,  and  even  hurtful. 

1726.  The  action  of  this  substance  appears  to  be  specifically 
upon  the  uterine  fibres;  urging  them  sooner  or  later  to  more  or 
less  violent  contraction.  It  is  not  the  alternate  contraction  alone 
that  is  increased  by  this  substance;  the  tonic  is  also  powerfully 
augmented,  which  is  of  much  more  value,  since  it  can  in  conse- 
quence of  this  power,  be  most  advantageously  employed  in  many 
cases  where  this  effect  would  be  all-important.  In  this  respect  its 
effects  appear  to  be  very  different  from  every  other  stimulant 
which  has  an  influence  upon  this  organ,  such  as  opium,  the  oil  of 
cinnamon,  volatile  alkali,  &c.  or  the  mechanical  stimulus  of  the 
forceps,  vectis,  or  the  hand.t 

*  It  is  more  than  probable  that  the  powers  of  tliis  substance  over  the  uterine 
fibre  was  known  in  Germany  long  before  it  attracted  notice  in  either  France,  or 
in  this  country.  The  German  name  for  this  substance,  according-  to  Goupil,  is 
illustrative  of  such  knowledg-e;  the  erg-ot  is  called  "  mutter  korn,"  or  womb 
grain,  mutter  signifying  womb.  This  conjecture  is  strengthened  by  a  fact 
mentioned  to  me  by  Dr.  Loi'ain  of  Philipsburg,  Pennsylvania.  He  says  he  was 
called  to  the  assistance  of  a  very  old,  self-created  midwife,  then  many  years  from 
Germany.  He  found  that  she  had  given  large  doses  of  the  infusion  of  the  se- 
cale  cornutum  before  his  arrival,  the  use  of  which  .she  declared  she  had  learned 
previously  to  leaving  her  own  country.  The  insulated  situation  of  this  woman's 
place  of  residence;  her  almost  entire  ig-norance  of  the  English  language;  her 
long  residence  in  the  neighbourhood  in  which  she  was  found;  the  little  com- 
munication she  could  have  with  enlightened  society;  and  the  little  disposition 
she  manifested  to  gain  information  in  her  profession,  renders  it  next  to  certain, 
that  she  had  become  acquainted  with  the  properties  of  the  ergot  before  she  left 
Germany,  as  she  has  declared;  a  period  long  antecedent  to  our  knowledge  of  it 
in  this  country,  and  perhaps  as  early  as  it  was  known  in  France. 

f  I  have  never\vitnessed  any  exaltation  of  the  powers  of  the  arterial  system, 
or  any  other  marked  effect,  (if  we  except  its  specific  action,)  from  the  exhibition 


616  ON  THE  SECALK  CORNUTUM,   OR  ERGOT. 

1727.  Each  of  the  stimulants  just  mentioned,  has  been  known 
to  rouse  the  alternate  contractions  of  the  uterus  into  a  temporary 
and  sometimes  successful  action;  but  after  neither,  does  the  tonic 
contraction  follow,  with  any  marked  degree  of  certainty;  nay, 
we  may  with  much  truth  declare,  that  the  inertia  of  this  organ  is 
very  apt  to  follow  their  employment.  Thus  we  witness  hajmor- 
rhage  sometimes  follow  the  use  of  either  of  the  remedies  just 
named,  though  they  may  have  been  successfully  exerted,  as  re- 
gards the  mere  delivery.  But  so  far  as  my  own  experience  goes, 
or  a  pretty  extensive  inquiry  will  justify  the  declaration,  I  can 
say,  that  neither  myself  nor  such  of  my  friends  of  whom  I  have 
asked  the  question,  have  ever  witnessed  such  a  consequence  fol- 
low the  use  of  the  ergot. 

1728.  So  far  then,  I  think,  we  may  with  much  confidence  de- 
clare, that  every  other  stimulus  which  has  contributed  to  the 
energy  of  the  uterus,  except  the  ergot,  has  been  followed  occa- 
sionally by  inertia  of  this  organ;  this  fact  is  of  high  practical 
importance;  as  it  leads  us  to  an  almost  certain  mode  of  treating 
such  females,  as  may  be  habitually  liable  to  floodings  after  deli- 
very. It  also,  on  the  other  hand,  points  out  a  caution  of  equal  prac- 
tical usefulness;  namely,  not  to  exhibit  it,  when  there  may  be  a 
chance  that  turning  may  be  necessary;  but  more  of  this  presently. 

1729.  There  is  another  peculiarity  attending  the  action  of  this 
substance,  not  less  remarkable  perhaps,  though  not  equally  im- 
portant, as  those  just  noticed;  namely,  the  promptitude  of  its  ac- 
tion; for  we  have  constantly  observed,  that  if  it  do  not  manifest 
an  influence  in  twenty  minutes,  or  half  an  hour  at  farthest,  it  ut- 
terly fails.  The  action  of  this  substance  is  generally  so  extremely 
prompt,  as  sometimes  to  create  a  doubt  of  its  agency  in  the  minds 
of  those  unaccustomed  to  its  operation.  But  I  am  every  way  cer- 
tain, that  the  "ergot"  never  acts  with  so  much  efficacy,  as  when 

of  the  erg-ot,  though  I  have  been  very  attentive  to  the  subject.  But  it  is  de- 
clared by  Dr.  Oslere,  on  the  authority  of  Dr.  Erskine  and  others,  that  it  slightly 
increases  the  fulness  and  frequency  of  the  pulsej  produces  a  glow  over  the 
surface;  excites  nausea,  and  sometimes  vomiting;  pain  and  giddiness  of  the 
liGSid,— Philadelphia  Journal  of  the  Medical  and  Physical  Sciences,  No.  III.  New 
Series. 

As  far  as  I  have  been  able  to  determine,  the  effects  of  tliis  substance  are 
confined  to  tlie  nervous  system;  and  through  its  intervention  acts  specifically 
upon  the  uterus.  Nor  are  its  powers  confined  to  the  human  uterus  ;  it  acts 
with  equal  and  similai-  efficacy  upon  the  uterus  of  the  brute.  "We  are  told,  it 
is  familiarly  used  neai-  Lyons  to  aid  the  parturient  cow. 


ON  THE  SECALE  CORNUTUM,  OR  ERGOT.  617 

it  acts  quickly;  indeed,  I  might  say,  that  its  success  is  almost  in 
proportion  to  its  promptitude.*  By  many,  this  very  sudden  ac- 
tion of  the  uterus  has  been  attributed  to  coincidence,  rather  than 
to  the  effect  of  this  remedy.  This  occasionally  is  certainly  the 
ca'se;  as  we  see  changes,  similar  to  those  effected  by  the  "ergot," 
take  place  as  suddenly  where  none  has  been  exhibited;  but  it 
would  be  unfair  to  declare  this  to  be  the  case  always. 

1730.  Thus,  on  the  11th  November,  1827, 1  was  called  to  Mrs. 
V,  in  labour  with  her  fifth  child;  the  waters  had  discharged 
themselves  half  an  hour  before  my  arrival,  and  the  patient  had 
experienced  a  number  of  very  smart  pains.  After  the  escape  of 
the  liquor  amnii,  the  pains  abated  in  force  and  frequency.  On 
the  accession  of  a  pain,  I  examined  my  patient,  and  found  the 
presentation  to  be  a  first  presentation,  and  the  head  arrived  at 
the  inferior  strait;  the  mouth  of  the  uterus  was  fully  dilated,  and 
everything  gave  promise  of  a  speedy  delivery.  But  the  pains 
became  still  more  feeble,  and  longer  apart;  and  after  wailing  an 
hour  and  a  half  for  their  amendment  without  advantage,  I  resolved 
upon  exhibiting  the  ergot;  especially,  as  my  patient  became 
clamorous  for  its  exhibition.  The  ergot  was  accordingly  sent 
for;  the  messenger  had  scarcely  left  the  house,  before  the  pouters 
of  the  uterus  were  spontaneously  roused,  and  with  such  efficacy, 
that  the  child  was  upon  the  point  of  being  born  when  it  arrived; 
it  was  therefore  not  given;  ten  minutes  more,  were  all  that  was 
necessary,  for  the  completion  of  the  delivery.  In  this  case,  had 
the  ergot  been  given,  the  alteration  in  the  action  of  the  uterus, 
would  doubtless  have  been  attributed  to  it,  by  those  unacquainted 
with  the  peculiarities  of  its  action;  yet  an  experienced  eye  and 
ear,  would  readily  have  detected  its  want  of  efficacy,  did  it  exert 
no  power,  as  well  as  be  able  to  determine  its  agency,  if  it  had 
really  awakened  the  powers  of  the  uterus. 

1731.  As  regards  myself,  I  have  the  most  firm  reliance  upon  the 
powers  of  the  "ergot;"  and  the  character  of  its  action  is  so 
distinctly  marked,  that  a  very  little  observation  will  lead  us  to 
detect  it.  Whether  the  peculiarity  of  the  effort  produced  by  the 
ergot  has   been   observed   by  others,  I  cannot  say  ;t  it  appears, 

•  Goiipil  says,  « la  rapidite  avec  laquelle  le  seig-le  a  produit  son  effect  est 
reelement  suprenantc;  elle  peut  etre  comparee  a  Taction  de  I'emetiqiie. 

t  Many  speak  of  its  specific  action;  or  of  its  specific  influence,  but  I  do  not 
recollect  to  have  seen  any  account  of  the  details,  in  which  these  specific  effects 
consist. 

78 


618  ON  THE  SECALE  CORNUTUM,  OR  ERGOT. 

however,  to  be  perfectly  well  defined  and  highly  characteristic; 
and  I  think,  I  am'  always  able  to  distinguish  the  cases  of  coinci- 
dence, from  those  in  which  the  ergot  was  decidedly  operating. 

1732.  When  ergot  has  been  successfully  administered,  we  find 
the  uterine  effort  not  only  more  quickly  repeated,  and  more 
powerfully  exerted,  but  these  efforts  are  accompanied  with  less 
suffering  than  thd  same  apparent  exertions  of  this  organ,  when  it 
is  not  urged  to  action  by  this  drug.  The  woman  when  interro- 
gated with  respect  to  her  feelings,  expresses  her  sensations  by 
saying,  she  feels  "as  if  everything  was  forcing  from  her;"  but 
at  the  same  time  admits,  that  the  pains  have  not  the  same  cha- 
racter with  those  she  suffered  before:  indeed,  it  very  frequently 
happens  that  there  is  a  great  abatement  of  suffering,  by  convert- 
ing a  concentrated  pain,  and  this  most  frequently  in  the  back,  to 
a  more  generally  diffused  one  over  the  abdomen;  or  by  obliging 
the  back  to  participate,  if  the  abdomen  has  been  the  particular 
seat  of  it.  At  the  same  time  it  must  be  confessed,  that  the  inter- 
vals between  the  contractions  are  more  uncomfortable,  as  an  al- 
most constant  nisus  is  kept  up  by  the  excited,  or  as  it  would  seem, 
the  goaded  uterus,  though  the  sensation  does  not  amount  to  pain. 
Now  the  presence  of  the  circumstances  just  noticed,  constitute 
the  peculiarity  of  the  action  of  the  secale  cornutum. 

1733.  Some  of  my  medical  friends,  but  they  are  very  few  in- 
deed, declare  they  have  never  witnessed  cuiy  effect  whatever  from 
the  ergot,  even  when  it  has  been  administered  in  large  doses.* 
I  account  for  this  discrepancy  in  result,  only  by  supposing 
the  ergot  which  they  employed  was  effete;  a  circumstance,  I 
have  reason  to  believe  from  experience,  of  no  unusual  occurrence, 

1734.  The  like  want  of  faith  in  the  powers  of  this  article,  seems 
to  prevail  with  many  respectable  practitioners  in  Europe,  and 
which  may  be  accounted  for  perhaps,  upon  the  same  principle. 
Dr.  Davis,  an  accoucheur  of  deserved  eminence,  says,  that  "  the 
pretensions  of  the  secale  cornutum  have  been  generally  known  to 
the  profession  for  nearly  twenty  years;  yet  the  actual  fact  of  its 
power  has  not  been  satisfactorily  established;  nor  is  there  evi- 
dence of  its  having,  in  a  single  instance,  superseded  the  necessity 
of  using  the  forceps. '"t     This  assertion,  it  must  be  observed,  is 

*  Chauslcur  and  Madame  La  ChapcUe,  declare  .they  l)ave  never  witnessed 
any  effects  from  the  crg-ot,  in  the  trials  they  made  of  it,  in  "la  Maternite  de 
Paris." 

f  Elem.  of  Oper.  Midwifery. 


ON  THE  SECALE  CORNUTUM,  OR  ERGOT.  619 

one  which  admits  of  no  possible  demonstration  ;  since  it  would 
be  impossible  to  prove  that  the  case  in  which  the  ergot  appeared 
to  be  successful  would  absolutely  have  required  the  use  of  the 
forceps,  or  that  the  cases  relieved  by  the  forceps  might  not  in 
many  instances  have  been  successfully  treated  by  the  ergot;  yet 
so  far  1  can  safely  aver,  that  a  number  of  instances  have  occurred 
in  which  I  believe  I  should  have  employed  the  forceps,  pre- 
viously to  my  acquaintance  with  the  powers  of  the  ergot;  but 
which  were  terminated  by  this  drug,  both  promptly  and  safely. 
And  farther,  I  am  certain,  that  I  do  not  use  the  forceps  once  now, 
were  I  used  them  formerly  ten  times. 

1735.  And  the  reason  of  this  abatement  in  the  employment  of 
the  forceps,  may,  I  think,  be  justly  attributed  to  the  almost  uni- 
versal use  of  the  ergot,  by  every  kind  of  practitioner  of  mid- 
wifery; and  hence  I  presume,  that  the  secale  cornutum,  now 
achieves  deliveries  that  would  have  required  the  forceps  former- 
ly; for  were  this  not  the  case,  I  think  I  should  be  called  upon  as 
formerly,  to  aid  labours  with  these  instruments. 

1736.  As  everything  almost  depends  upon  the  proper  preser- 
vation, and  quality  of  the  ergot,  it  should  be  kept  whole,  in  a  glass 
bottle  with  a  ground  stopper;  and  only  powdered,  pro  re  nata; 
nor  should  we  ever  use  it  after  it  exceeds  a  year  in  age,  if  possible 
to  prevent  it.*  For  the  ergot,  like  almost  every  other  vegetable 
substance,  is  easily  acted  upon  by  heat  and  moisture  ;  and  con- 
sequently is  easily  deteriorated,  when  exposed  to  their  influence. 
I  have,  in  several  instances,  failed  to  produce  the  slightest  eflect 
with  the  ergot  procured  at  one  shop  ;  whilst  that  from  another, 
in  the  same  patient,  has  been  as  prompt,  as  efficacious. 

1737.  I  have  generally  administered  the  ergot  in  substance; 
some  prefer  it  in  infusion. t     Twenty  grains  in  a  little  sugar  and 

•  We  are,  however,  informed  by  I.orinsor,  (Edinb.  Med.  and  Surg-.  Journal 
for  Oct.  1826,  p.  453,  that  it  preserves  itspowei-s  perfectly  for  two  years,  as  far 
as  i-egards  its  operation  on  the  stomachs  of  men  ;  but  whether  it  retains  its  spe- 
cific powers  upon  the  uterine  fibre  for  that  period,  does  not  appear  to  have 
been  ascertained  by  his  experiments.  On  the  other  hand,  we  are  directed  by 
Goupil,  (Journal  des  Progres  des  Sciences,  et  Institution,  &c.  vol.  iii.  1827, 
p.  170,)  in  order  to  be  certain  of  the  pecuhar  properties  of  this  substance,  to  use 
it  the  same  year  in  which  it  has  been  collected ;  and  that  it  must  be  kept  in 
bottles  hermetically  sealed,  and  not  be  powdered,  but  as  it  may  be  wanted. 

f  Bordot  informs  us  that  the  old  woman  in  fhe  department  of  "  Cote  d'or,'' 
infuse  a  handful  of  this  substance  in  a  cup  of  water,  and  give  a  table-spoonful  of 
it  every  five  minutes.     This  dose,  Goupil  observes,  is  much  stronger  than  that 


620  ON  THE  SECALE  CORNUTUM,   OR  ERGOT 

water  may  be  given  at  once;  and  I  seldom  exceed  this  quantity, 
as  I  have  rarely  found  the  farther  exhibition  of  it  attended  with 
better  effect.  My  valued  friend,  the  late  Dr.  George  Holcombe, 
of  Allentown,  New  Jersey,  objects  very  strongly  to  the  quantity 
just  named;  and  purposes  much  smaller  doses,  but  more  frequently 
repeated;  or  as  often  as  it  may  be  necessary.  But  as  the  whole  of 
Dr.  Holcombe's  observations  on  this  subject  are  of  great  practical 
value,  I  feel  I  shall  be  doing  a  general  good,  as  well  as  performing 
a  duty,  to  give  them  at  length,  together  with  some  observations 
upon  them. 

"  Jillentown,  K  J.  Nov.  21,  1825. 

"  Dear  Sir — I  have  just  finished  reading  your  System  of 
Midwifery,  and  have  to  request  you  to  accept  my  thanks,  in  com- 
mon with  the  profession,  for  the  much  novel  and  valuable  infor- 
mation which  it  contains. 

'^Permit  me  to  call  your  attention,  for  a  few  moments,  to  se- 
veral subjects  which  have  been  but  briefly  noticed  in  your  work; 
the  first  is  Ergot.  This  extraordinary  agent  owes  its  introduction 
into  the  materia  medica  entirely  to  American  physicians;  and  as 
yours  is  the  first  system  of  Midwifery  which  has  issued  from  an 
American  source,  since  its  use  has  become  general,  the  profession, 
both  here  and  abroad,  looked  to  your  pages  for  a  more  particu- 
lar account  of  tl)e  properties  and  uses  of  ergot  than  has  heretofore 
been  given.  I  am  afraid  they  will  be  much  disappointed,  as  I 
frankly  declare  to  you  I  have  been,  in  finding  it  passed  by  almost 
unnoticed.  Much,  it  is  true,  has  already  been  written  concerning 
it;  and,  1  am  aware,  that  practitioners  are  supposed  to  be  well- 
informed  as  to  its  properties,  and  the  cautions  necessary  to  be  ob- 
served in  its  administration.  But  this  I  am  persuaded  is  a  mistake 
— and,  in  my  opinion,  you  could  not  more  efiicientiy  subserve 
the  cause  of  humanity,  and  obstetrics,  than  by  devoting  a  chapter, 
in  the  next  edition  of  your  work,  to  the  consideration  of  the  uses 
and  abuses  of  this  article. 

"  The  scruple  dose,  as  a  general  prescription  for  aiding  the  ex- 
j)ulsive  stage  of  labour,  I  am  convinced,  from  considerable  experi- 
ence, is  exceptionable  and  dangerous.     In  ordinary  cases,  no  mis- 


pointed  out  by  accoucheurs;  but  he  says  we  must  notice  the  manner  in 
which  it  is  taken,  as  it  is  much  less  active  than  when  griven  in  powder. — Ibid 
p. 171. 


W^   '■  ON  THE  SEC  ALE  CORNUTUM,   OR  ERGOT.  621 

chief,  it  is  acknowledged,  will  result  from  the  exhibition  of  so  large 
a  dose.  But  the  child,  if  it  be  unusually  large,  or  the  pelvis 
faulty,  or  if  the  accoucheur  have  to  contend  with  a  first  labour, 
will  always  be  put  to  imminent  danger,  and  frequently  destroyed 
by  scruple  doses,  when  its  safe  delivery  might  have  been  effected, 
either  by  the  unassisted  energies  of  the  mother,  or  by  small  divi- 
sions of  the  dose,  frequently  repeated. 

"  Your  zeal  in  proscribing  the  use  of  the  crotchet,  will  doubt- 
less obtain,  as  it  certainly  merits,  the  plaudits  of  your  brethren 
— at  least  of  the  more  enlightened  portion  of  them.  But  if  the 
use  of  the  terrible  instrument  just  named  be  as  reprehensible,  (and 
who  will  presume  to  deny  it  ?)  as  you  have  represented  it,  how 
much  less  so,  or  rather  how  much  more  so,  is  the  intemperate  use 
of  an  agent  which  sacrifices  a  four-fold,  if  not  a  twenty-fold  greater 
number  of  victims?  More  children,  I  am  satisfied  from  what  I 
have  seen  and  heard,  have  already  perished  by  the  injudicious 
use  of  ergot,  during  the  few  years  which  have  followed  its  intro- 
duction into  the  practice  of  this  country,  than  have  been  sacrificed 
bjj^  the  unwarrantable  use  of  the  crotchet  for  a  century  past!  This, 
if  correct,  is  a  most  serious  fact;  and  of  its  truth  I  do  not  entertain 
the  slightest  doubt. 

"  But  notwithstanding  the  strong  language  I  have  just  used,  I 
regard  ergot,  when  cautiously  administered,  as  a  most  interesting 
and  valuable  adjuvant  in  the  practice  of  midwifery.  I  have  used 
it  constantly,  since  Dr.  Stearns  first  called  the  attention  of  phy- 
sicians to  it.  For  some  time  I  used  the  scruple  doses,  or  corres- 
ponding doses  of  the  decoction,  which  I  am  afraid,  are  every 
where  yet  too  common,  but  soon  abandoned  this  practice  in  con- 
sequence of  several  fatal  demonstrations  of  its  impropriety.  Since 
then  I  have  administered  it  in  very  small  doses — say  from  two  to 
three  grains,  which  I  repeat  as  often  as  may  be  necessary  ;  and 
in  this  manner,  I  am  general/7/  ah\e  to  effect  my  object;  and 
always  without  injury  to  the  mother  or  child.  In  fact,  I  have 
never  known  a  child  perishing  from  ergot,  administered  iir  this 
cautious  manner.  I  prescribe  it  now  unhesitatingly  in  first  la- 
bours, and  even  in  cases  of  contracted  pelvis;  and  such  is  the  ex- 
traordinary energy  imparted  to  the  uterus,  by  the  slow  but  per- 
severing mode  of  exhibition  which  I  have  adopted,  that  I  have 
very  rarely  found  it  necessary,  for  several  seasons  past,  to  resort 
to  the  use  of  the  forceps. 

"  Independently  of  the  power  of  the  ergot  in  aiding  the  expul- 


622  ON  THE  SECALE  CORNUTUM,  OR  ERGOT. 

sion  of  the  child,  it  seems  to  possess  other  important  properties 
in  the  practice  of  midwifery.  I  have  never  seen  a  case  of  puer- 
peral fever  follow  its  administration.  This  fact  may  be  accidental, 
and  confined  to  my  experience;  but  the  remark  I  have  thought 
might  be  interesting  to  you  as  a  teacher  of  midwifery— at  least 
worth  noticing.*  It  sometimes  completely  extinguishes  the 
lochia;  but  this  effect  has  never  resulted,  as  far  as  I  have  observ- 
ed, in  injury  to  the  mother.!  I  prescribe  it,  which  I  believe  is 
a  common  practice,  when  flooding  after  delivery  is  apprehended. 
Also  in  cases  of  partial  prolapsus  of  the  uterus,  and  of  habitual 
bearing-down,  from  whatever  cause  the  last  distressing  affection 
may  arise;  and  I  am  much  deceived,  if  great  comfort  is  not  fre- 
quently derived  from  this  precautionary  exhibition  of  the  medi- 
cine, in  each  of  the  diseases  just  specified.!  But  1  am  afraid  I 
am  extending  my  observations  beyond  your  time  and  patience; 
I  will  therefore  close  them,  by  re])eating  the  suggestion  which 
I  have  already  taken  the  liberty  to  make — that  you  would  confer 
a  great  benefit  upon  midwifery,  by  devoting  a  chapter  in  the 
next  edition  of  your  work,  to  the  medicinal  history  of  ergot. 
The  profession,  T  repeat,  expect  it  of  you;  and,  permit  me  to  add, 
from  the  situation  which  you  occupy  in  American  obstetrics, 
has  a  right  to  expect  it  of  you."     But  to  return: 

1738.   I  think  I  am  right,  when  I  say  there  is  no  decisive 

*  It  would  be  a  most  valuable  acquisition  to  our  remedial  means,  did  the 
««  erg-ot"  contribute  to  the  lessening  of  the  cases  of  puerperal  fever.  Upon 
this  point,  I  can  say  nothing-  practically;  it  may  be  true,  as  stated  by  Dr. 
Holcombe,  that  this  may  be  confined  to  his  own  experience,  or  rather  that  it 
may  be  merely  coincident;  yet  it  deserves  serious  attention  ;  for  this  substance 
may  have  a  prophylatic  power.  I  would,  therefore,  earnestly  recommend  this 
subject  to  the  attention  of  the  accoucheurs  of  oui-  country,  and  especially  to 
those  who  may  inhabit  districts,  in  which  this  too  fatal  disease  sometimes  be- 
comes epidemic. 

•J-  "It  sometimes  completely  extinguishes  the  lochia."||  I  have  never  seen 
this  effect  follow  the  use  of  the  "  ergot."  Nor  do  I  believe  it  generally  neces- 
sary that  it  should  do  so ;  for  if  the  labour  have  been  well  conducted  through 
all  its  stages,  the  lochia  will  rarely  be  too  abundant.  See  Cliapter  on  the  Lo- 
chia. Yet  it  may  be  highly  important  to  be  in  possession  of  a  remedy  when  the 
diminution  of  the  lochia  may  be  an  object. 

if  The  usefulness  of  the  "ergot"  in  the  last  specified  affection;  namely,  "ha- 
bitual bearing  down,"  is  certainly  contrary  to  all  reasoning  upon  the  subject ; 
and  would  be,  if  correct,  one  of  tlie  many  instances,  in  which  we  are  obliged 
to  make  speculations  yield  to  experience. 

i  I  presume  Dr.  H.  only  means  by  "  ExtinguiMng  the  lochia,"  a  great  dimi- 
nution of  it. 


ON  THE  SEC  ALE  CORNUTUM,  OR  ERGOT.  623 

instance  extant,  in  which  the  "ergot"  has  had  a  direct  unfriendly- 
influence  upon  the  child.  I  am  aware  much  has  been  said  to  the 
contrary  by  many  respectable  practitioners;  but  I  think  it  would 
be  no  difficult  matter  to  show,  that  when  a  still-born  child  has  fol- 
lowed the  exhibition  of  the  "  ergot,"  it  has  been  constantly  owing 
to  the  following  circumstances.  First.  It  has  been  given  too 
early;  that  is,  long  before  any  reasonable  expectation  should 
have  been  entertained,  that  delivery  would  soon  follow  its  ex- 
hibition, owing  to  the  want  of  relaxation  in  the  soft  parts.  Second. 
Given  when  the  head  has  not  been  well  situated,  and  the  practi- 
tioner perhaps,  not  aware  of  this  circumstance;  consequently, 
making  a  wrong  estimate  of  the  time  that  must  elapse  before  de- 
livery could  take  place,  after  its  exhibition.  This  error  very 
commonly  arises  from  the  facility  with  which  the  head  of  the 
child  may  generally  be  felt;  or  its  supposed  dispositions  to  es- 
cape through  the  external  parts;  because  t^y,  as  well  as  the 
uterus,  are  favourably  disposed.  No  mistake  is  more  common 
than  this,  among  practitioners  who  are  ignorant  of  the  mecha- 
nism of  labour;  for  they  suppose  there  is  but  little  to  do;  and 
"  were  the  pains  but  a  little  stronger,  the  child  would  soon  be 
delivered."  Under  this  delusion  the  ergot  is  given,  with  every 
expectation  of  a  speedy  issue.  But  this  does  not  take  place  agree- 
ably to  their  hopes,  and  very  much  to  their  surprise,  for  they  are 
altogether  unable  to  account  for  the  failure.  Whereas  an  enlight- 
ened practitioner  would  instantly  have  detected  the  wrong  posi- 
tion of  the  head,  and  would  have  seen  at  once  how  much  was  yet 
to  be  efiected,  before  delivery  could  take  place.  He  would  also 
have  been  able  to  determine  very  nearly  the  time  and  the  de- 
gree of  effort  it  would  have  required  to  terminate  the  labour; 
and  the  ergot  would  have  been  withheld  until  more  had  been 
done  by  the  unaided  contractions  of  the  uterus.  But  the  better 
to  illustrate  this  fruitful  source  of  error,  we  will  first  refer  to  the 
position  of  the  head,  when  not  well  situated;  and  second,  to  the 
difficulty  the  head  sometimes  finds  in  undergoing  these  changes, 
even  when  it  is  well  situated;  though  the  soft  parts  may  be  fa- 
vourably disposed. 

1739.  1st.  The  difficulty  arising  from  the  position  of  the  head. 
Thus  in  the  fourth,  fifth,  and  sixth  presentations,  there  may  be 
much  delay,  from  the  forehead  being  sometimes  obliged  to  come 
under  the  arch  of  the  pubes,  as  in  the  fourth  and  fifth  probably, 
if  not  changed,  and  unavoidably  in  the  sixth;  which  circumstance 


624  ON  THE  SECALE  CORNUTUM  OR  ERGOT. 

may  have  escaped  the  calculation  of  the  practitioner  at  the  lime 
he  exhibited  the  ergot;  or  he  may  have  been  ignorant  of  it;  con- 
sequently much  unlooked-for  delay  may  ensue,  and  this  some- 
times to  the  injury  of  the  child,  and  the  uterine  parietes.  But  in 
this  case,  no  blame  should  attach  to  the  "ergot"  specifically; 
for  the  same  consequences  will  follow  from  the  long-continued 
efforts  of  the  uterus,  where  none  of  this  substance  has  been  ad- 
ministered. Baudelocque  gives  us  instances  of  this  kind;  and 
every  practitioner  of  any  standing  must  have  observed  the  same 
thing;  indeed,  the  danger  of  the  child  after  the  evacuation  of  the 
waters,  is  always  in  proportion  to  the  tonic  power,  and  the  con- 
tinuance of  the  alternate  contractions  of  the  uterus;  hence  we 
have  always  reason  to  apprehend, that  the  child  will  be  still-born, 
when  the  uterine  contractions  continue  very  long,  and  with  much 
force,  after  the  discharge  of  the  liquor  amnii;*  we  are  persuaded 
this  is  agreeably  to^ie  experience  of  all  who  practise  midwifery. 
If  this  be  so,  when  no  "ergot"  has  been  administered,  it  may 
certainly  a  fortiori  happen,  after  it  has  been  given,  without  any 
blame  being  justly  attached  to  its  powers.  Some  have  carried 
their  apprehensions  of  this  substance  so  far  as  to  declare  it  will 

*  It  is  evident  from  the  nature  of  the  communication  between  the  mother  and 
child  while  in  utero,  that  the  latter  is  altogether  dependent  upon  the  continuance 
of  circulation  for  its  life;  that  this  circulation  is  maintained  bv  means  of  the 
placenta;  and,  consequently,  will  be  more  or  less  perfect,  or  cease  entirely,  as 
this  mass  may  preserve  its  connection  with  the  uterus  unrestrainedly,  be  embar- 
rassed, or  have  its  cells,  or  vessels  altogether  obliterated,  by  the  degree  of  force 
exerted  by  the  contracting  uterus.  And  that  the  degree  of  compression  which 
the  placenta  may  suffer,  will  be  in  the  direct  ratio  of  the  power  of  the  tonic, 
and  the  frequency  and  force  of  the  alternate  contractions  of  the  uterus;  now 
the  former  will  be  strict  almost  in  proportion  to  the  time  that  elapses  after  the 
waters  have  escaped;  and  the  latter  will  be  repeated,  as  often  as  the  suscepti- 
bility of  the  uterus  will  enable  it  to  contract.  It  will  follow  then,  that  whatever 
increases  the  tonic  and  alternate  contractions,  will  increase  the  circumstances 
just  named  as  being  unfavourable'to  the  security  of  the  child,  and  which  must 
necessarily  be  augmented  in  proportion  to  the  delay,  which  supervenes,  from 
the  rupturing  of  the  membranes,  to  the  birth  of  the  child.  If  then,  the  ergot 
be  given  after  the  waters  are  evacuated,  and  much  delay  take  place  in  the  de- 
livery, the  child  must  almost  necessarily  suffer;  not  because  the  ergot  has  an 
unfriendly  influence  directly  upon  it,  but  because  it  was  given  when  the  uterus 
had  too  much  resistance  to  overcome;  a  delay  is  thus.created,  which  exposes  the 
placenta  to  every  degree  of  compression,  even  to  the  entire  stopping  of  the 
circulation  within  it — when  this  h.ippens,  the  ehild  must  die,  if  not  very  speedily 
relieved  from  its  thraldom;  and  hence,  we  see  children  still-born,  sometimes 
after  the  use  of  the  ergot. 


ON  THE  SECALE  COUNUTUM,  OH  ERGOT.  625 

produce  vesications,  and  inflict  other  injuries  upon  the  child's 
skin,  in  the  short  time  that  shall  elapse  hetvveen  its  exhibition 
and  the  final  termination  of  the  labour.  This  is  even  more  in- 
comprehensive,  and  incredible,  than  the  influence  of  the  imagina- 
tion upon  the  foetus  in  utero;  at  least  it  should  be  classed 
with  it. 

1740.  Second.  The  difficulty  the  head  sometimes  finds  in  un- 
dergoing the  changes  necessary  for  its  escape  from  the  pelvis? 
when  the  soft  parts  are  well  disposed. 

1741.  This  may  arise  from  several  causes.  First,  when  a  pro- 
per relation  does  not  exist  between  the  head  and  the  pelvis,  even 
when  the  head  is  well  situated.  When  this  happens  a  long  series 
of  efibrts  will  be  required,  to  force  the  posterior  fontanelle  to 
place  itself  under  the  arch  of  the  pubes;  and  nothing  but  an  en- 
larged experience,  with  an  entire  knowledge  of  the  mechanism 
of  labour,  will  enable  the  practitioner  to  determine  the  quantity 
offeree,  and  the  lapse  of  time  that  will  be  required  for  this  pur- 
pose. In  this  case,  should  the  "ergot"  be  resorted  to,  it  will  be 
blamed  if  the  child  be  still-born,  when  it  is  altogether  the  fault 
of  the  practitioner— for  in  this  case,  the  "  ergot"  should  not  have 
been  given,  so  long  as  the  natural  pains  continued  powerful;  for, 
it  is  not  so  much,  by  multiplying  the  force,  as  by  repeating  its 
application,  that  the  desirable  end  is  eflected.  We  have  known 
the  <«ergot"  given  under  these  circumstances,  and  the  uterus  to 
become  exlwusted  by  being  thus  unduly  urged:  and  the  only  re- 
source ultimately  has  been  in  the  forceps.  Second,  at  other  times, 
when  the  posterior  fontanelle  has  even  placed  itself  under  the 
arch  of  the  pubes,  it  will  sometimes  require  the  long-continued 
and  the  often-repeated  efibrts  of  the  uterus,  to  carry  the  parietal 
protuberances  below  the  tubers  of  the  ischia.  Now,  if  "ergot" 
be  given  in  this  case,  it  may  be  blamed,  if  the  child  be  still-born, 
when  it  had  no  agency  in  the  disaster. 

1742.  Dr.  Henry  Davies  says,  "it  may  be  observed,  that  in 
some  cases,  when  the  pelvis  was  a  little  confined,  and  when  the 
head  was  not  sufficiently  low  down  for  the  application  of  the  com- 
mon forceps,  the  secale  has  been  successfully  used,  and  the  child 
delivered  with  the  forceps:  very  great  discretion  in  these  cases 
is  required."*  Dr.  Davies  gives  several  well  marked  instances 
of  the  influence  of  the  ergot  in  feeble  action  of  the  uterus. 

*  Med.  and.  Phys.  Jouinal,  July  and  August,  1825. 
79 


626  ON  THE  SECALE  CORNUTUM,   OR  ERGOT. 

1743.  But  certainly  the  most  common  cause  of  the  failure  of 
the  "ergot"  is  owing  to  its  injudicious  and  indiscriminate  exhi- 
bition. It  has  been  given,  we  have  well  ascertained,  before  the 
membranes  have  been  ruptured;  the  os  uteri  not  at  all  dilated, 
and  the  external  parts  quite  rigid.  What  but  defeat  and  injury- 
can  result  from  such  an  improper  use  of  this  powerful  aider  of 
uterine  contraction?  This  substance  is  now  in  familiar  use  among 
midwives,  who  have  neither  principles  nor  experience  to  direct 
its  proper  employment;  and  we  are  credibly  informed,  it  is  used 
in  this  city  by  a  practitioner  in  extensive  business,  in  almost 
every  case  to  which  he  is  called. 

1744.  This  is  truly  the  abuse  of  a  valuable  remedy;  for  if  our 
information  be  correct,  the  too  free  use  of  it  in  this  gentleman's 
practice,  has  occasioned  very  many  cases  of  prolapsus  uteri. 
This  effect  of  the  ergot  may  perhaps  be  questioned  by  some,  but 
I  have  not  the  smallest  doubt  of  the  fact,  from  what  I  have  seen^ 
when  this  medicine  had  been  improperly  taken.  A  lady  aborted 
at  a  little  beyond  the  fifth  month  with  twins.  The  involucra 
did  not  come  away  for  several  days  after  the  expulsion  of  the 
embryos;  and  as  they  came  off  in  one  mass,  very  soon  after  tak- 
ing twenty  grains  of  "ergot"  in  powder,  the  lady  could  not  be 
persuaded  but  that  one  of  the  placentae  remained,  and  became 
very  anxious  for  its  discharge,  and  desired,  that  another  dose  of 
the  ergot  might  be  given  her — this  I  absolutely  refused;  but  at 
the  same  time  assured  her,  in  the  most  positive  terms,  that  no- 
thing remained  to  come  away.  It  seems,  however,  that  she  was 
not  convinced ;  for  I  had  scarcely  left  the  house,  before  she  caus- 
ed another  portion  of  the  ergot  to  be  given  her.  The  conse- 
quences were,  a  repetition  of  violent  pains,  and  the  escape  of  a 
considerable  portion  of  the  uterus  through  the  os  externum.  She 
became  now  excessively  alarmed,  and  I  was  sent  for  in  haste.  I 
found  her  in  great  agony;  an  agony  resembling  that  of  the  last 
moments  of  labour;  and  upon  examination,  the  uterus  was  found 
in  the  situation  just  mentioned. 

1745.  The  uterus,  owing  to  the  constant  and  violent  nisus 
created  by  the  ergot,*   was  restored   with  some  difficulty ;  and 

•  This  effect  of  the  ergot  has  often  been  noticed?  the  impression  it  makes 
upon  the  nervous  system  remains  a  long  time;  sometimes  even  after  this  sub- 
stance has  been  rejected  from  the  stomach;  in  this  respect,  it  is  Hke  opium,  and 
some  other  narcotics.  Desgranges  assures  us  he  has  seen  this;  yet  the  delivery 
has  gone  on  with  equal  speed  and  certainty. 


ON  THE  SECALE  CORNUTUM,  OR  ERGOT.  627 

the  pains  were  appeased  after  awhile  by  large  doses  of  laudanum. 
She  was  obliged  to  wear  a  pessary  for  a  long  time,  before  the 
uterus  recovered  its  position. 

1746.  I  am  therefore  persuaded,  that  much  future  injury  may 
be  sustained,  by-giving  this  medicine  in  cases  where  there  is  lit- 
tle or  no  resistance  to  be  overcome;  for  in  such  cases  the  increas- 
ed efforts  of  the  uterus,  produced  by  the  ergot,  continue  after  the 
child  is  delivered,  as  its  impression  does  not  immediately  wear 
off;  this  took  place  in  this  case  at  a  time  when  the  uterus  had 
nothing  to  support  it,  or  to  retain  it  within  the  pelvis;  it  must, 
therefore,  become  prolapsed,  if  not  protruded, 

174-7.  From  what  has  been  said,  it  would  appear  that  the  ergot 
is  a  powerful  medicine;  so  powerful  indeed,  that  well  defined 
rules  should  be  laid  down  for  its  use.  It  would  seem,  that  it  is 
the  improper  exhibition  of  this  drug,  and  not  a  specific  power, 
that  creates  the  evils,  but  too  commonly  charged  to  it ;  also,  that 
there  is  no  satisfactory  evidence,  of  its  exercising  any  baneful 
effects  upon  the  child  in  utero. 

1748.  The  following  rules  for  the  use  of  the  ergot,  if  attended 
to,  I  think  will  prevent  any  evil  following  its  exhibition. 

1749.  1st.  It  should  never  be  given  before  the  membranes  are 
ruptured  ;  the  os  uteri  dilated,  and  the  external  parts  disposed  to 
yield. 

1750.  2d.  It  must  not  be  used,  so  long  as  the  natural  pains  are 
efficient,  and  competent  to  the  end. 

1751.  3d.  But  should  they  flag,  from  any  cause,  it  may  be 
given,  provided,  the  labour  be  a  natural  labour,  according  to  our 
acceptation  of  the  term  "  natural  labour;"  that  is,  v^hen  the  head, 
(if  well  situated,)  the  breech,  the  feet,  or  the  knees  present.  For, 
independently  of  any  accident  which  may  complicate  the  labour, 
it  is  sometimes  desirable,  for  the  safety  of  the  child,  to  hasten  it, 
when  the  natural  powers  are  incompetent  to  this  end. 

1752.  4th.  And  if  the  labour  be  accompanied  by  any  such  ac- 
cident as  flooding,  convulsions,  syncope,  &c.  (see  par.  651)  it  may 
sometimes  be  employed  to  great  advantage,  provided  rules  1  and 
2  are  not  violated. 

1753.  5th.  It  may  be  used  very  often  with  much  advantage 
in  every  kind  of  premature  labour;  and  at  full  time,  when  the 
placenta  is  not  thrown  off,  and  the  uterus  is  found  in  a  state  of 
atony. 

1754.  6th.  Where  flooding  takes  place  after  the  rupture  of  the 


628  ON  THE  SECALE  CORNUTUM,   OR  ERGOT. 

membranes  the  os  uteri  well  dilated;  the  pains  feeble,  but  the 
child  well  situated,  and  the  pelvis  well  conformed. 

1755.  7th.  Where  the  head  of  the  child  has  been  left  in  the 
uterus  by  being  separated  from  its  body. 

1756.  8th,  Where  the  uterus  is  painfully  distended  by  coagula. 

1757.  Dr.  Ward,  of  New  Jersey,  recommends,,that  the  ergot 
should  be  used,  "  in  alarming  uterine  haemorrhages,  which  some- 
times take  place  before  delivery,  whether  it  takes  place  in  con- 
sequence of  a  detachment  of  some  portion  of  the  placenta,  it  being 
attached  to  the  fundus  uteri,  or  whether  it  be  owing  to  a  separa- 
tion of  its  attachment  over  the  orifice  of  the  uterus."  In  this 
advice,  I  cannot  agree  with  this  respectable  practitioner;  for,  in 
the  first  instance  he  states,  there  can  be  no  advantage  derived 
from  exciting,  or  increasing  pain,  unless  the  os  uteri  be  well 
opened,  and  the  membranes  protruding,  that  they  may  be  rup- 
tured, if  this  can  be  done  with  propriety;*  for  until  the  liquor 
amnii  be  expended,  the  haemorrhage  cannot  be  arrested  by  ex- 
citing the  alternate  contraction  of  the  uterus;  and  the  tonic,  by 
which  this  discharge  can  alone  be  stopped,  under  such  circum- 
stances, cannot  take  place,  until  the  membranes  have  given  way. 

1758.  In  the  second  case  in  which  Dr.  Ward  proposes  the  er- 
got, we  apprehend  it  would  be  decidedly  mischievous;  as  it  is 
found,  that  in  placental  presentations,  the  flooding  is  always  in- 
creased by.  pain;  as  it  directly  tends  to  augment  the  separation 
of  the  placenta. 

1759.  It  may,  however,  be  said,  that  in  the  unavoidable  hcemor- 
rhage,  that  an  advantage  may  be  derived  from  the  exhibition  of 
the  ergot,  by  hastening  the  labour,  though  it  may  for  a  short  time 
increase  the  discharge.  But  in  order  that  this  reasoning  may  have 
any  value  as  a  practical  precept,  the  cases  in  which  this  advan- 
tage could  be  derived,  should  be  extremely  well  defined;  nothing 
should  be  left  contingent  in  a  complaint  so  dangerous,  and  which 
has  but  one  successful  mode  of  treatment,  so  far  as  we  yet  knov/; 

*  "We  say,  "  if  the  membranes  can  be  ruptured  with  propriety;"  for  this 
cannot,  nor  should  not  always  be  resorted  to?  for  instance,  it  should  never  be 
done  where  the  presentation  is  not  natural,  unless  we  mean  to  proceed  imme- 
diately to  ai-tificial  delivery.  And  if  tliis  should  be  deemed  expedient,  there 
can  be  no  propriety  in  g-iving  the  ergot,  for  the  less  opposed  we  are  by  pain* 
during  turning,  the  better.  It  therefore,  also  follows,  that  this  substance  should 
not  be  given  in  cases,  where  it  will  be  certainly  necessary  to  turn;  especially, 
if  the  waters  have  long  been  drained  off. 


ON  THE  SECALE  CORNUTUM,  OR  ERGOT.  629 

namely;  the  delivery  of  the  child.  Now,  with  these  admissions, 
we  are  every  way  disposed  to  recieve  any  evidence  in  favour  of 
the  remedy  proposed,  and  for  the  particular  species  of  haemorrhage 
in  question.  And  if  Dr.  Ward  will  assure  us  from  his  own  ex- 
perience, that  the  ergot  will  supersede  the  necessity  of  artificial 
delivery,  from  the  promptness  with  which  it  eflfects  delivery,  we 
will  hail  this  substance,  as  one  of  the  most  valuable  of  our  thera- 
peutical remedies;  but  until  this  be  done,  we  shall  feel  a  reluc- 
tance to  adopt  this  remeny,  in  the  cases  under  consideration,  as 
reasoning  appears  to  be  decidedly  against  its  employment. 

1760,  Let  me  be  borne  with  a  little  longer,  as  this  subject  is 
one  of  high  interest  in  every  point  of  view;  for  a  placental  pre- 
sentation is  always  one  of  great  danger,  even  under  the  best  ma- 
nagement: and  it  is  almost  necessarily  fatal,  under  bad.  Do  not 
let  me  be  supposed,  in  this  investigation,  to  substitute  reasoning 
for  facts;  for  the  very  contrary  would  be  my  wish.  But  until  I 
shall  be  in  possession  of  unequivocal  testimony  in  its  favour,  I 
shall  remain,  at  least  doubtful,  of  the  safety  of  employing  it. 

1761.  I  have  in  so  many  words  declared,  that  reasoning  is 
against  the  use  of  the  ergot,  in  the  unavoidable  haemorrhage;  I 
will  now  endeavour  to  show  this  to  be  the  case.  The  primary 
object  in  all  cases  of  haemorrhage  is  to  arrest  the  bleeding;  now, 
in  the  cases  in  question,  this  is  particularly  necessary,  if  it  be 
even  temporarily;  and  for  this  purpose  a  variety  of  means  are 
resorted  to;*  but  this  cannot  be  done  absolutely,  but  by  deli- 
very. Why  should  delivery  be  the  only  certain  remedy  in  this 
case?  For  several  reasons;  first,  because  a  temporary  suspension 
of  the  bleeding  is  no  security  against  its  return;  as  the  very  me- 
chanism of  labour  causes  the  placenta  to  detach  itself  from  the 
mouth  of  the  uterus;  and  when  this  takes  place,  haemorrhage 
must  ensue;  and  this  in  the  exact  ratio  to  the  extent  of  the  sepa- 
ration. Second,  this  being  the  case,  it  follows,  that  whatever 
tends  to  increase  this  separation  will  necessarily  augment  the 
bleeding — uterine  contractions  have  this  tendency;  and  the  er- 
got is  almost  certain  to  provoke,  or  increase,  uterine  contraction; 
consequently,  to  increase  haemorrhage.  Third,  because  pains 
may  exist  for  some  time,  without  the  os  uteri  being  disposed  to 
yield;  yet  during  the  return  of  each  pain,  the  hemorrhage  is  in- 
creased: consequently,  if  the  uterine  contractions  be  increased  ia 

*  See  Chapter  on  Uterine  Hceinorrhage  from  the  locution  of  the  placeiitii. 


630  ON  THE  SECALE  CORNUTUM,  OR  ERGOT. 

force  or  frequency  by  any  agency  whatever,  and  the  mouth  of 
the  uterus  does  not  dilate  in  the  same  proportion,  mischief,  in- 
stead of  good,  must  be  the  result. 

1762.  For  these  reasons,  we  areof  opinion,  that  the  ergot  should 
not  be  used  in  cases  of  placental  presentations,  as  a  general 
practice;  and  if  used  at  all,  it  should  only  be  when  the  os  uteri 
is  well  dilated,  or  easily  dilatable.  In  such  cases  it  may  be  occa- 
sionally useful,  by  urging  the  uterus  to  brisker  contractions,  and 
thus  effect  the  delivery  of  the  child  as  speedily,  perhaps,  as  when 
turning  is  had  recourse  to;  especially,  if  this  must  be  attempted  by 
the  inexperienced  practitioner. 

1763.  The  ergot  may  be  used  with  a  fair  prospect  of  success, 
when  the  head  of  the  child  has  been  left  within  the  cavity  of  the 
uterus,  after  the  delivery  of  its  body,  when  no  objection  can  arise 
from  the  unhealthy  condition  of  the  pelvis, 

1764.  I  have  also  derived  much  advantage  in  several  cases  of 
monorrhagia;  where  the  long  continuance  of  the  disease,  rather 
than  the  immediate  excess  of  the  quantity  discharged,  rendered 
it  important  it  should  be  arrested.  I  have  given  in  such  cases, 
three  grains  three  times  a  day,  in  the  form  of  a  pill,  and  contin- 
ued it  for  some  time. 

1765.  It  may  also  be  useful  in  cases  of  polypi,  when  it  shall  be 
desirable  to  force  these  substances  beyond  the  neck  of  the  uterus, 
for  the  purpose  of  applying  a  ligature,  or  with  a  view  to  their 
excision.  I  have  some  time  since  suggested  its  probable  useful- 
ness in  hydatids  of  the  uterus;"^  and  its  value  in  such  cases  has 
been  in  part  realized  by  Dr.  Macgill.t 

*  See  Treatise  on  the  Diseases  of  Females,  Chapter  on  "  Hydatids  of  the 
Uterus,"  by  the  Author. 

•j-  See  his  interesting  case  in  the  American  Journal  of  the  Medical  Sciences, 
No.  I.  November,  1827,  and  also  in  the  chapter  just  referred  to. 


FJ.,t 


(   631   ) 

EXPLANATION  OF  PLATE  l. 

(from  baudelocque.) 

A,  A,  A,  A,  The  ossa  ilia,  properly  so  called, 
a,  a,  The  iliac  fossae. 
bb,  bb,  The  angle  which  divides  transversely  and  obliquely 
from  behind  forward,  the  internal  face  of  the  os 
ilium  into  two  parts,  and  which  makes  part  of  the 
brim  of  the  pelvis. 
CO,  cc,  The  cristse  of  the  ossa  ilia, 
e,  e,  The  anterior  superior  spine  of  the  ossa  ilia. 

f,  f.  The  angle  formed  by  the  internal  lip  of  the  crista  of 

the  ilium  towards  the  extremity  of  its  anterior 
two-thirds,  and  to  which  is  attached  a  ligament  in- 
serted at  the  other  end  in  the  transverse  apophysis 
of  the  last  lumbar  vertebra. 

g,  g.  The  inferior  angle  of  the  os  ilium,  which  makes  part 

of  the  acetabulum. 
B,  B,  The  OS  ischium, 
h,  h.  The  tuberosities  of  the  ischia. 
i,  i,  The  branches  of  the  ischia. 
k,  k.  The  posterior  parts  of  the  ossa  ischia,  which  make 

parts  of  the  acetabula. 
C,  C,  The  bodies  of  the  ossa  pubis. 
1,  1,  The  angles  of  the  ossa  pubis, 
m,  m,  The  posterior  extremities  of  the  ossa  pubis,  which 
make  part  of  the  acetabula. 
n,  n,  The  descending  branches  of  the  ossa  pubis,  which 
unite  with  those  of  the  ischia. 
D,  D,  D,  The  os  sacrum. 
1,  2,  3,  4,  The  anterior  sacral  holes. 
o,  o,  o.  The  base  of  the  sacrum, 
p,  p,  The  sides  of  the  sacrum. 

E,  The  coccyx. 

F,  The  lumbar  vertebra. 

r,  r,  The  transverse  apophyses  of  the  vertebra. 


(   632   ) 

s,  s,  The  ligaments  which  go  from  the  transverse  apo- 
physes of  the  last  vertebra,  to  the  angle  of  the  in- 
ternal lips  of  the  crystse  of  the  ilia,  indicated  by  the 
letters,  f,  f. 
t,  t,  Two  other  ligaments  which  descend  from  the  same 
apophyses  to  the  superior  edge  of  the  sacro-iliac 
symphyses. 
G,  G-,  The  femurs  or  thigh  bones. 

V,  V,  The  heads  of  the  femurs  received  into  the  aceta- 
bula. 
u,  u,  The  foramina  ovalia. 

Symphyses  of  the  bones  of  the  pelvis. 

H,  The  symphysis  of  the  ossa  pubis. 
I,  I,  The  sacro-iliac  symphyses. 
K,  The  sacro-vertebral  symphysis. 


FL.M. 


(      633      ) 


EXPLANATION  OF  PLATE  TI. 
This  figure  represents  the  Entrance  of  a  well-formed  pelvis. 

a,  a,  The  iliac  fossse. 

b,  The  sacro-vertebral  angle,  or  the  projection  of  the  sa- 

crum. 

c,  The  last  lumbar  vertebra. 

d,  d,  The  lateral  parts  of  the  base  of  the  sacrum. 

e,  e,  The  sacro-iliac  symphyses. 

f,  f,  The  parts  over  the  acetabula. 
g,  The  symphysis  of  the  pubes. 

The  lines  indicate  the  different  diameters  of  the  superior  strait. 

A,  B,  The  antero -posterior,  or  little  diameter. 

C,  D,  The  transverse,  or  great  diameter. 

E,  F,  The  oblique  diameter,  which  extends  from  the  left  aceta- 
bulum to  the  right  sacro-iliac  junction. 

G,  H,  The  oblique  diameter,  which  goes  from  the  right  acetabu- 
lum to  the  left  sacro-iliac  junction. 


SO 


(      634      ) 


EXPLANATION  OF  PLATE  III. 

This  figure  represents  the  inferior  .strait  of  a  well-formed  pelvis. 

a,  a,  The  external  faces  of  the  osso  ilia. 

b,  b,  The  anterior  superior  spines  of  the  ossa  ilia. 

c,  c,  The  anterior  inferior  spines  of  the  ossa  ilia. 

d,  d,  The  acetabula. 

e,  e,  The  foramina  ovalia,  with  the  obturator  ligaments, 
f,  f,  The  ischiatic  tuberosities, 
g,  g,  The  ossa  pubis. 

h,  h,  The  branches  of  the  ossa  pubis  and  ischia  united, 
i,  ij  The  sacrum. 
k,  The  coccyx. 
1, 1,  The  sacro-ischiatic  ligaments, 
m,  The  symphysis  of  the  pubes. 
n,  n,  The  arch  of  the  pubes. 

The  lines  indicate  the  diameters  of  the  inferior  strait. 

A,  A,  The  antero-posterior  diameter  or  great  diameter. 

B,  B,  The  transverse  or  small  diameter. 
C,  C,  D,  D,  The  oblique  diameters. 


I'L^ITE   JII 


L'LATE   IV 


(      635      ) 


EXPLANATION  OF  PLATE  IV. 

This  figure  represents  a  deformed  pelvis. 

a,  a,  The  ossa  ilia. 

b,  b,  The  ossa  pubis. 

c,  c,  The  ossa  ischia. 

I,  d,  d,  The  last  lumbar  vertebra. 

e,  The  projection  of  the  sacrum, 
f,  f,  The  sacro-iliac  symphyses. 

g,  The  symphysis  of  the  pubes. 
h,  h,  The  foramina  ovalia. 

i,  i,  The  branches  of  the  ossa  pubis  and  ischia,  which  form  the 
anterior  arch  of  the  pelvis. 
k,  k,  The  acetabula. 

The  lines  indicate  the  diameters  of  the  superior  strait. 

A,  A,  The  antero-posterior  diameter;  its  natural  width  reduced 

to  fourteen  or  fifteen  lines,  or  so  many  portions,  twelve 
making  an  inch. 

B,  B,  The  transverse  diameter — its  length,  in  this  subject,  four 

inches,  ten  lines. 

C,  C,  The  distance  from  the  projection  of  the  sacrum,  to  that  of 

the  margin  which  answers  to  the  left  acetabulum,  thir- 
teen lines, 

D,  D,  The  distance  from  the  same  point  of  the  sacrum,  to  that 

of  the  margin  which  answers  to  the  right  acetabulum, 
twenty  lines. 


(      636      ) 


EXPLANATION  OF  PLATE  V. 

This  plate  is  intended  to  represent  the  first  presentation  of  the 
vertex,  or  where  the  posterior  fontanelle  is  behind  the  left  ace- 
tabulum, and  the  anterior  to  the  right  sacro-iliac  symphysis. 
In  this  position,  the  head  offers  itself  diagonally  to  the  open- 
ing of  the  superior  strait;  the  left  ear  will  correspond  with 
the  right  foramen  ovale,  and  the  chin  is  pressed  against  the 
sternum. 

a,  The  left  acetabulum. 

b,  b,  The  symphysis  of  the  pubes. 

c,  c.  The  oval  foramens. 

d,  The  spine  of  the  ilium. 

e,  The  uterus. 

f.  The  dots  indicating  the  posterior  fontanelle. 

g,  The  anterior  fontanelle,  or  right  sacro-iliac  symphysis. 
h,  The  arch  of  the  pubes. 


I,  ii 


The  tubers  of  the  ischia. 


k,  k,  The  margin  of  the  pelvis,  or  superior  strait. 

For  the  mechanism  of  this  labour,  see  page  226. 
For  the  mode  of  turning  in  it,  see  p.  272. 
For  the  application  of  the  forceps,  see  p.  301,  par.  816,  and 
following. 


FLjr. 


ru  ri 


(     637     ) 


EXPLANATION  OF  PLATE  VL,  OR  SECOND  PRESEN- 
TATION. 

a,  The  right  acetabulum. 

b,  The  symphysis  of  the  pubes. 

c,  Left  foramen  ovale. 

d,  Spine  of  the  right  ilium. 

e,  The  uterus. 

f,  Dots  representing  the  site  of  the  posterior  fontanelle. 

g,  Anterior  fontanelle,  or  left  sacro-iliac  symphysis, 
h,  Arch  of  the  pubes. 

i,  Tuber  of  the  left  ilium. 

For  the  mechanism  of  this  labour,  see  page  227. 
For  the  mode  of  turning,  see  p.  273. 

For  the  application  of  the  forceps,  see  p.  302,  par.  819,  and 
following. 


(      638      ) 


EXPLANATION  OF  PLATE  VIL,  OR  THIRD  PRESEN- 
TATION. 

a,  Left  acetabulum, 

b,  b,  Symphysis  pubes. 

c,  Left  foramen  ovale. 

d,  Spine  of  the  right  ilium. 

e,  The  uterus. 

f,  The  posterior  fontanelle,  indicated  by  the  dots. 

g,  Left  sacro-iliac  symphysis, 
h,  Arch  of  the  pubes. 

i,  Tuber  of  the  left  ischium. 

For  the  mechanism  of  this  labour,  see  page  227. 
For  the  mode  of  turning,  see  p.  273. 
For  the  application  of  the  forceps,  see  p.  303,  par.  820,  and 
following. 


FL.  YUL. 


(     639      ) 


EXPLANATION  OF  PLATE  VIIL,  OR  FOURTH  PRE- 
SENTATION. 

a,  Left  acetabulum. 
b,  b,  Symphysis  pubes. 

c,  Left  foramen  ovale. 

d,  Spine  of  the  ilium. 

e,  The  uterus. 

f,  Anterior  fontanelle,  indicated  by  the  dots. 

g,  Right  sacro-iliac  symphysis. 
h,  Arch  of  the  pubes. 

i,  Left  tuber  of  the  ischium. 

For  the  mechanism  of  this  labour,  see  page  228. 
For  the  mode  of  turning,  see  p.  274. 

For  the  application  of  the  forceps,  see  p.  304,  par.  824,  and  fol- 
lowing. 


(      640     ) 


EXPLANATION  OF  PLATE  IX.,  OR  FIFTH  PRESEN- 
TATION. 

a,  Right  acetabulum. 

b,  Symphysis  pubes. 

c,  Right  foramen  ovale. 

d,  Spine  of  the  ilium. 

e,  The  uterus. 

f,  Anterior  fontanelle,  indicated  by  the  dots. 

g,  Left  sacro-iliac  symphysis, 
h,  Arch  of  the  pubes. 

i,  Tuber  of  the  ischium, 
k,  k,  Margin  of  the  pelvis. 

For  mechanism  of  this  labour,  see  page  233. 
For  the  mode  of  turning,  see  p.  274. 

For  the  application  of  the  forceps,  see  p.  304,  par.  825,  and  fol- 
lowing. 


FL.  IT. 


rL.x. 


(      641      ) 


EXPLANATION  OF  PLATE  X.,  OR  SLXTH  PRESEN- 
TATION. 

a,  Right  acetabulum, 
b,  b,  Symphysis  pubis. 

c,  Foramen  ovale. 

d,  Spine  of  the  ilium. 

e,  The  uterus. 

f,  Anterior  fontanelle  behind  the  symphysis  pubes,  as  indicat- 

ed by  the  dots. 

g,  Left  sacro-iliac  symphysis, 
h,  Arch  of  the  pubes. 

i.  Tuber  of  left  ischium. 

For  the  mechanism  of  this  labour,  see  page  233. 
For  the  mode  of  turning,  see  p.  275. 

For  the  application  of  the  forceps,    see  p.  305,  par.  828,  and  fol- 
lowing. 


SI 


(      642      ) 


EXPLANATION  OF  PLATE  XL 

Fig.  L 

This  plate  represents  the  niiddle-sized  pessary. 
Froni  a,  a,  Two  inches  and  four-tenths. 

b,  A  central  hole  to  permit  any  discharges  to  pass,  three- 
tenths  of  an  inch  in  width, 
c,  c,  An  excavation  for  the  neck  of  the  utei-us  to  lie  in, 
when  applied. 

Fig.  IL 

Is  a  central  section  of  the  same  pessary. 

a,  a,  Represents  the  internal  cavity  of  the  pessary. 

b,  b,  Represents  the  depth  of  the  excavation  of  c,  c,  of  Fig  1. 

5.2  tenths  of  an  inch  deep. 
c,  A  section  of  the  central  hole,  b,  of  Fig.  1. 


FI,.Wl^ 


S,rli,iii    thiiiiiijli  (lie  Uiiln 


]■•]-••.]. 


J'liiii 


(      643      ) 


EXPLANATION  OF  PLATE  XIL 


EXPLANATION  OP  THE  FORCEPS  OP  PROFESSOR  SIEBOLD. 

I  have  been  fovoured,  by  the  politeness  of  Dr.  Eberle,  with  a 
sight  of  Professor  Sicbold's  forceps.  In  their  general  form  and 
size,  they  differ  but  little  from  the  forceps  of  Baudclocque;  they 
are  rather  longer  in  the  clams,  and  a  little  more  curved,  as  will 
be  seen  by  examining  the  plates. 

What  I  value  in  them  is,  their  very  ingenious  mode  of  lock- 
ing; I  am  persuaded  this  has  a  decided  advantage  In  some  po- 
sitions of  the  head,  and  will  contribute  to  the  success  of  appli- 
cation. 

Fig.  I. 

a,  The  top  of  the  screw  which  serves  to  unite  the  blades. 

b,  The  head  of  the  shoulder  of  the  screw,  which  is  received  a 

very  small  way  into  the  countersink  f.  fig.  2. 

c,  The  conical  body  of  the  screw,  which  is  received  into  the 

excavation  g.  fig.  2. 

d,  The  cut  part  of  the  screw,  which  passes  into  the  female 

screw  cut  in  the  body  of  the  blade  of  the  forceps. 

e,  The  head,  or  but,  against  which  the  lower  extremity  of  the 

screw  is  received. 

Fig.  II. 

f,  The  countersink  for  receiving  the  shoulder  b,  fig.  1. 

g,  The  conical  excavation  for  the  reception  of  c,  fig.  1. 

Fig.  III. 

The  forceps  united  and  reduced  to  one-half  the  proper  size, 
h,  h.  The  manner  in  which  the  screw  unites  the  blades, 
i,  i,  The  turned  extremities  of  the  handles,  which  serve  like 
those  of  Baudelocque,  as  blunt-hooks. 


(      644      ) 


EXPLANATION  OF  PLATE  XIII. 

The  forceps  represented  in  Plate  XIII.  are  reduced  two-thirds 
from  the  proper  size — ^^they  are  called  the  long  French  forceps, 
or  Baudelocque's  forceps,  though  they  differ  a  little  from  them, 
but  not  materially.  These  instruments  are  well  made  by  Mr. 
John  Rorer,  No.  26,  North  Sixth  street,  from  a  Paris  pattern. 


J'J^iTE  A' lit 


PLATE  XIY. 


PLATE  XT 


(      645      ) 


EXPLANATION  OF  PLATE  XIV. 

a,  The  body  of  the  uterus,  reduced  to  about  hall"  its  natural 

size  after  labour. 

b,  The  hollow  formed  by  the  depression  of  the  fundus. 

c,  The  neck  of  the  uterus,  contracted. 

d,  The  OS  tincae. 

e,  e,  The  membranous  expansions  by  which  the  uterus  is  con- 
nected with  the  pelvis. 


(      646      ) 


EXPLANATION  OF  PLATE  XV. 

a,  The  body  of  the  uterus  inverted  and  reduced  to  about  half 

its  natural  size  after  labour. 

b,  The  neck  contracting  firmly  on  the  protruding  fundus. 

c,  Tlie  fundus  escaping  through  the  os  uteri. 

d,  The  depression  formed  by  the  inversion  of  the  fundus. 

e,  e,  The  membranous  expansions  which  connect  the  uterus  with 
the  pelvis. 


^:^- 

^;.-^. 


FLATE  jn. 


(     G47     ) 


EXPLANATION  OF  PLATE  XVI. 

a,  a,  a,  The  fundus  and  body  of  the  uterus  escaping  through  the 
OS  uteri,  reduced  to  about  half  its  natural  size  after 
labour. 

b,  The  neck  of  the  uterus  firmly  embracing  the  inferior 

portion  of  the  body. 

c,  The  vacancy  left  at  the  upper  portion  of  the  neck  of  the 

uterus. 
d,  d,  d,  The  connecting  membranous  expansions  of  the  uterus. 


(      G48      ) 


EXPLANATION  OF  PLATE  XVIL 

a,  a,  The  body  and  fundus  of  the  uterus.* 

b,  The  neck  of  the  uterus  inverted  with  the  body  and  fundus. 

c,  The  OS  uteri  looking  into  the  abdomen. 

d,  d,  The  connecting  membranous  expansions  of  the  uterus. 

•  III  making  the  above  drawings,  our  only  aim  Avas  to  make  the  mechanism 
of  inversion  clearly  understood.  We  have  therefore  divested  the  uterus  of  all 
its  appurtenances,  except  that  by  which  it  is  connected  with  the  vagina,  that 
the  figures  need  not  be  confused.  For  the  same  reason  we  have  represent- 
ed the  uterus  delivered  of  the  placenta. 


FLATH    XVn 


\k(\       d 


^ 


isis»  ^^- 


PLATE    XVm. 


\:.i^ 


Fiff.H.  , 


(     649     ) 


EXPLANATION  OF  PLATE  XVII 1. 

FIG.  1. 

a,  a,  a,  The  umbilical  cord  prolapsed  before  the  presenting  part 
of  the  child. 

FIG.  II. 

a,  a,  An  elastic  gum  catheter  of  the  size  called  No.  8,  reduced 
to  one-half  its  breadth  and  length. 

b,  Thestillet. 

c,  The  eye  of  the  catheter. 

d,  A  loop  of  riband   or  tape  passed  over  the  cord,  both  ex- 

tremities of  which  are  made  to  pass  through  the  eye,  c, 
and  descend  a  little  below  the  external  extremity  of  the 
catheter.  It  will  be  seen  by  this  arrangement,  that  the 
upper  extremity  of  the  catheter  can  be  put  in  contact 
with  the  cord,  by  drawing  the  ends  of  the  riband  with- 
out, and  gently  pressing  the  instrument  upward;  and 
when  there,  it  may  be  kept  in  that  situation,  by  forcing 
the  point  of  the  stillet  upwards;  or  the  loop  can  be 
loosened  by  withdrawing  the  stillet,  or  ceasing  to  draw 
upon  the  external  ends  of  the  riband, 
e,  e,  The  extremities  of  the  riband. 

FIG.  til. 

a,  a,  The  body  of  the  catheter. 

b,  The  stillet. 

c,  The  eye  of  the  catheter,  through  which  the  riband  passes. 

d,  A  knot  tied  on  the  cord. 

e,  e,  The  external  extremities  of  the  riband. 

It  will  readily  be  perceived  that  if  the  ends  of  the  riband  in 
fig.  n.  be  drawn,  the  cord  and  the  extremity  of  the  catheter,  will 
be  brought  in  contact,  and  if  it  be  desirable  to  fix  it  in  this  posi- 

82 


(     650     ) 

tion,  it  can  be  done  instantly  by  forcing  the  stillet  bone;  and  if 
it  be  necessary  to  take  off  the  pressure  from  the  cord,  it  can  be 
readily  eflected  by  again  withdrawing  the  stillet  a  short  distance. 
Whereas  the  ligature  in  fig.  III.  is  permanent,  and  will  conse- 
quently maintain  a  uniform  pressure  upon  the  cord,  and  may 
even  arrest  the  circulation  within  it.  If  it  be  necessary  to  with- 
draw the  catheter  after  the  loop  is  returned,  it  can  be  done  in 
either  case  with  equal  facility  by  drawing  the  stillet  so  as  to  dis- 
engage its  point  from  the  riband,  where  it  passes  through  the 
eye  of  the  catheter,  and  then  removing  the  catheter  itself.  There 
will  be,  however,  this  difference  in  the  situations  of  the  ligatures; 
that  of  fig.  II.  will  be  without  compression  on  the  cord;  while 
that  of  fig.  III.  will  consantl)^  remain  the  same. 


DIRECTIONS  FOR  PLACING  THE  PLATES. 

The  plates  are  to  be  placed   at  the  end  of  the  book,  making 
them  face  their  explanations. 


T^IE    END. 


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